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SATS JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: l/1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'v G Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> ner`s Name <br /> Phone <br /> dress t -(—' City w (� <br /> antractor's Name cense <br /> S70& Phone t(` <br /> _PE OF WORK (Check) : NEW WELL / DEEPEN %% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION IZip P REPAIR / PUMP REPLACEMENT /-7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK EWER LINES PRIVY <br /> SEWAGE DISPO AL FIELD �- -CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Z__� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustrialCable Tool Dia. of Well Excavation / -1 <br /> f.4 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation Gravel Pack Depth of Grout Se <br /> Cathodic Protection Mary Type of Grout OG <br /> —Disposal Other Other Information <br /> Geophysical Surf Seal Installed <br /> n� <br /> IP INSTALLATION: Contractor <br /> Type of Pu < H.P. f <br /> QIP REPLACEMENT: / / State Work Done <br /> JMP '.REPAIR:_ / / State Work Done <br /> .TRUCTION OF WELL): Well Diameter /Approximate Depthc:� <br /> Describe Material and Procedure <br /> (ry✓yi/A 074fAti <br /> tereby agreto comply with all laws and regulations of the San Joaquid Local Health District <br /> ori the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :ter completion of 'my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> _:o on is true toasmi <br /> wl dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .I0R T UTING AND ( t <br /> ,NED TITLE �— <br /> PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 7ALICATION CCEPTED BY <br /> DATE <br /> )DITIONAL COMMENTS <br /> P I GR INSPECTION / P II FI AL INSPECTOtk <br /> PECTION BY DATE b INSPECTION BY / DATE <br />