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SAN JOAQUIN ~LOCAL HEALTH DISTRICT <br /> _'OFA.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> C <br /> Contractor's Name License 1Z3jePhone Zl2 ?� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY,LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE r _ 'TYPE-,OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial ~ Cable Tool Dia. of Well Excavation.. Q <br /> Domestic/private Drilled Dia, of Well Casing r � a <br /> Domestic/public Driven Gauge of Casing } , <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: "'Contractor.._ <br /> Type of Pump.. _. j H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP :REPAIR: State Work Done _. <br /> L� <br /> DESTRUCTION OF-WELL: Weh_l �Di' am r <br /> Approximate epth'® <br /> Describe Material a d Proce ure i, <br /> f <br /> I hereby agree to comply''wV h all ws and of the San Joaquin LocAl- Health District <br /> and the State of California p re taining-to....or_regulating„wetl.r_cons!t-ruction:---Within FIFTEEN DAIS <br /> after completion of my work on a new 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 the best of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT FINAL SP ION. <br /> SIGNED TITLE _ <br /> -' (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> i <br /> PHASE I FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rail. 1_7A Z177`r 0M <br />