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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfx,OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION "OR PUMP PERMIT Permit No. 7 � <br /> _THIS PERMIT EXPIRES I YEAR FROM 'DAT`9' IjS$UED Date Issued <br /> it a (Complete In Triplicate) <br /> Application is hereby made 'to the San Joaquin Local Health District for a permit .tdconstruct <br /> and/or install the work heriin described. This application"Is made in compliance with San Joaqui <br /> County Ordinance-No. 1862 <br /> � a d the.-Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT , <br /> Owner's Name 4 <br /> l Phone <br /> Ze <br /> Address. <br /> City'' <br /> Contractor's Name <br /> i LicensePhone <br /> TYPE OF WORK (Check): NEW"WELL " DEEPEN RECONDITION L7 DESTRUCTION /7 <br /> PUMP INSTTION ' PUMP REPAIR' P <br /> / / / UMP REPLACEMENT <br /> Other !� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEEPAGE PIT OTHER <br /> PROPEIiTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE jTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ <br /> - Industrial. - Cable Tool Dia. of Well Excavation4 <br /> Domestic/Private i r!Drilled Dia. of Well Casing <br /> j Domestic/public �^ ririven : Gauge of Casing _ ✓ `r <br /> Irrigation Gravel Pack Depth of Grout Seal \ <br /> Cathodic Protection Rotary .- Type of Grout <br /> Disposal Ocher Other Information' ' <br /> Geophysical Surface Seal installed By,' <br /> r <br /> PUMP INSTALLATION: Contractor s 1 <br /> Type; of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / { State Work Done <br /> PUMP ,REPAIR: /7 ), State Work Done <br /> DESTRUCTION OF WELL: Well- Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California-'pertaining to or regulating well'"construction. Within FIFTEEN DAYS <br /> after completion of my work -on anew well, I will furnish the San Joaquin Local Health District a <br /> + WELL DRILLERS REPORT of" the•well and notify them before putting..the.".well. in.use.... The above <br /> information is true to=th_e,best-of-my.:knowledge and belief. I WILL CALL 'FOR'A'GROUT INSPECTION <br /> 4 PRIOR TO UTING AND NAI. INS P CrIo ° <br /> SIGNED , . TITLE <br /> I: (DRAW T PLAN ON REVERSE SIb <br /> OR DEPARTMENT USE ONLY <br /> PHASE I �f <br /> APPLICATION ACCEPTED BY G: OATS <br /> ADDITIONAL COMMENTS: <br /> PHASE lI GROINSPECTION 113E A INSPECT ON <br /> I INSPE f ION BY r,6ZkjDATEINSPECTION BY E <br /> k.: E R 1626 Ran- i_74 � - )1/7q 7M <br />