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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22, <br /> THIS PERMIT EXPIRES' ] YEAR FROM DATE ISSUED Date. Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to 'the Sart Joaquin Local Health District for 'a' permit toconstruct <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 3 <br /> CENSUS TRACT <br /> Owner's Name- , - , -- <br /> Phone ' <br /> Address C $ <br /> Contractor's Name License...# Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN / RECONDITION /_7 DESTRUCTION /_7 <br /> E PUMP INSTALLATION /—/ PUMP REPAIR j/ PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP-REPAIR:, j�g State Work Done <br /> .RESTRUCTION OF WELL; Well Diameter . e - <br /> Describe Material and Procedure Approximate Depth <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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> information is true to the best of my knowledge and belief. The above <br /> SIGNED l% TITLE <br /> DRAW PLOT ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> CALL FOR A GROUT,INSPECTION .PRIOR TO GROUTING AND FINAL INSPECT I N. <br /> E H 1426 7172 1M -` <br />