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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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. 1862 and the Rules and Regulations of the Sant oaWn Local Heath District. <br /> ffOG►a til. was �.� <br /> JOB ADDRESS/LOCATION �r/ < +rr d . CENSUS TRACT <br /> Owner's Name E A.* Phone <br /> Address Le C."C City <br /> Contractor s Name <br /> License lt% , L6 / Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION /df" PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / T O <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <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 `C <br /> Drilled Dia. of Well Casing <br /> Domestic/private <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 /> Surface Seal installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor L&I V L'- �� H.P.Type of Pump .� P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> ry <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 thewell 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br />