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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE' SE: 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. i <br /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> Address IR City ' <br /> Contractor's Name License #,27 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN/ / RECONDITION / /-7/ ' DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- %s' I <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE IT OTHER <br /> PROPERTY LINE - PRI ATF. DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Ie .,Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y4,2 <br /> D mastic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack Depth of Grout Seal �� i <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done f J <br /> PUMP .REPAIR: / / State Work Done <br /> DE —TTRUCTION 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 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 tr to the best�gXknowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN A FI AL I <br /> SIGNED 14 TITLE <br /> DRAW PLO PLAN ON REVERSE SIDE <br /> C7 7 FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY = DATE 3 .- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY -/jam DATE <br /> 1 <br /> i <br /> 1177 _ 2M 4 <br />