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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. ,, Stockton Calif- <br /> Telephone: . (209) 466-6783 <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, instar, .the.work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance :No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 30s ADDREssILocATioN. Alb 4r Comr&, AJ , ,��Ta CENSUS. TRACT <br /> Owne' s Name a n e Phone <br /> t Address 37 rt City <br /> + Contractor's NameLS s License �.!phone .� <br /> TYPE OF WORK (Check): NEW-WELL /? DEEPEN '/? RECONDITION /� DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION 0 PUMP REPAIR / / PUMP REPLACEMENT %T <br /> Other J / <br /> x 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 By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �'0 <br /> f ..._ <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP a A/Ti State Work Done <br /> ES•TRUCTION OF WELL': Well Diaimeter 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 elief. I.WILL CALL FOR,A GROUT INSPECTION <br /> I PRIOR TO NG AND A FINAL INSPECT N. <br /> SIGNED TLE C7j__ „ <br /> (DRA OT P ON REV SE SIDE ` - _.. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDDATE <br /> . . <br /> ADDITIONAL COMMENTS: C17 <br /> PHASE II GROUV INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY IDATE INSPECTION DATE -7 <br /> t E 8. 1426 Rev. 1-74 1-74 2M <br />