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Y <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> io—R70FFICE USE: ��160'1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (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 Sari 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 No1; 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f CENSUS TRACT <br /> Owner's Name Phone 1 <br /> e <br /> Address . City ` <br /> Contractor's Name `_ License ( .Phone ' <br /> TYPE OF WORK (Check): NEW WELL -/-7 -DEEPEN %77 RECONDITION /-7 DESTRUCTION /-7 <br /> .PUMP INSTALLATION j / PUMP REPAIR-�� f <br /> PUMP REPLACEMENT % <br /> Other /J . . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial rx Cable Tool, Dia.- of Well Excavation \` <br /> _,,Domestic/private Drilled d Dia. of Well Casing <br /> Dome stic/pub lie -' Driven 3 Gauge of Casing �} <br /> Irrigation ., Gravel Pack• Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout ' <br /> Disposal tr Other Other Information; <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type tof PumpH <br /> .P• —F�i-- <br /> PUMP REPLACEMENT: . / `/ 4State Work Done 1 <br /> i <br /> PUMP ,REPAIR: , :,' 5tateyWork Done _ - �, <br /> DESTRUCTION OF WELL: Well Diameter . <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to'comply with=al.l 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 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.the­well. in..use. The above <br /> information is true to- the-best-of- my knowledge} and belief." I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO'GROUnNG SLD A F INSPECTT <br /> SIGNED I � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) F f _.-- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I } <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE I;I/FINAL INSPECTION <br /> INSPECTION BY DATE J1: INSPECTION BY DATE <br /> E H 1426 Dow 1...76 f 1,k7c� om <br />