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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�,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. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' ''° ' CENSUS TRACT 2a-f--030-ra <br /> Owner's Name6AP Phone _ 9 7. ...- <br /> Address City <br /> Contractor's Nam ;�' <br /> License � �� Phone S <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/7 RECONDITION /7, DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 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 /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> 'PUMP REPLACEMENT: . / / State Work Done <br /> PIW -.REPAIR: / f State Work Done P �x �z-, <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 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 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 �,, (mss- TITLE 1 <br /> W PLOT PLAN ON REVERSE SIDE <br /> I <br /> PHASE I <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: `�— <br /> PHASE II GIKOI"SMCTION PHASE ITJ7FINAL INSPECTION <br /> INSPECTION BY zATE INSPECTION BY DATE ± <br />