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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. �y <br /> Telephone: (209) 466--6781 �'1' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT Permit No. / 7 � 1��� <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 gpplication .is made in compliance with San Joaquin <br /> County Ordinance No. 1862 VC :h <br /> :;�� sand Regulations of the San Joaquin Local Health District. <br /> .305 ADDRESS/LOCATION /� CENSUS TRACT <br /> Owner's Name _ — Phone <br /> Address . City <br /> Contractor's Name icenseILPhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION-1--/—DESTRUCTION /? <br /> E. PUMP INSTALLATION _ PUMP REPAIR/ / PUMP REPLACEMENT 1_7 x <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6LI2 SEWER LINES PIT PRIVY <br /> .SEWAGE DISPOSAL FIELD rQ - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of .Well Excavation <br /> &,---flomestic/private Drilled Dia, of Well Casing �S <br /> Domestic/public gft Driven Gauge of Casing <br /> Irrigation NEW Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By:5%f_1kf 24 <br /> .lam <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump A.P. Lf . <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> s � <br /> PUMP .REPAIR: J / 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 pertaiui.nj�to or regulating well construction. Within FIFTEEN DAPS <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 my knowledge and belief./I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A FINAL INSPECTION <br /> SIGNED TITLE <br /> (DRAIJ PLOT PLAN ON REVERSE SID <br /> FUR. DEPARTMENT USE-ONLY` ---- <br />�� PHASE I ---- � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ., DAT <br /> -. <br /> -74 <br /> E H 1 +26 Rev. • 1 <br />