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ro SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' ///per?� <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 I a. Name w ; �a Phone ' <br /> Address d o ZJ - �'G <br /> _ City <br /> Contractor's Name License Phone �i6 �-g62S <br /> TYPE OF WORK (Check): NEW WELL. /_7 DEEPEN /7 I RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIRPUMP REPLACEMENT/7 <br /> Other i7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p\ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL �I <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 . " I <br /> .Irrigation .� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 11 <br /> Disposal - Other Other Information ' <br /> Geophysical Surface Seal Inistalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: . /-7 State Work Done <br /> PUMP .REPAIR: `-S-tate Work Done i <br /> ff <br /> DESTRUCTION OF WELL: Well Diameter / 9 App oxi,mate 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 C <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..wel.l. 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 SIDE) ` <br /> PHASE. I <br /> FOR DEPARTMENT-USE ONLY <br /> . <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II S IO P INSPECTI <br /> INSPECTION BY DATE INSPECTIONr ATE f <br />