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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FO—r,-"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 ,6-,,�:2l <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein d . ion is made in compliance with San Jo4quin . <br />. County Ordinance No. 1862 and the Rules andRe ul ti ns a he San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION <br /> � �� �� CENSUS TRACT <br /> Owner's Name44 <br /> Phone�4465^ �� <br /> Address 442 Be Ar City � Q f <br /> ' f <br /> Contractor's Name License #��� Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION /-7 ` <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other 1 I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ! <br /> Domestic/private Drilled Dia. of Well Casing , <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 /> t Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SlAb H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> IPUMP .REPAIR: / / State Work Done <br />� DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 /> iinformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> (PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED # TITLE :Ij <br /> (DRAW PILOT PIM OX REVERSE SIDE i <br /> FOR DEPARTMENT USE ONLY <br /> : PHASE I <br /> APPLICATION ACCEPTED BY DATE �- - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/F NAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ell <br /> vto /77 - 2M <br />