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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOESOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (204) 466-6781 � 7`// <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. la 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 1 <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. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> �( i <br /> Address � � City <br /> g <br /> Contractor's Name a License IOU Phone <br /> t. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /- <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 z <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 <br /> Seal In talled By: <br /> PUMP INSTALLATION: Contractor / � <br /> Type of Pump - H.P. 15z <br /> PUMP REPLACEMENT: / State Work Don <br /> PUMP REPAIR: / / 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 a <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 DR,ItLERS--REPORT-of' th-e-well-and notify--th-em-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 UTING A. FINAL INSPECTION. <br /> SIGNED L TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> Y <br /> FOR DEPARTMENT USE ONLY ! <br /> PHASE I <br /> APPLICATION ACCEPTED BY E DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSTIECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> �f 2M a <br />