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7 t:r _m <br /> D SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'OE:OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,. �y <br /> i <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 Joaqu3n� <br /> County Ordinance No, 1862 and the Rules and Regu_1_ations of the San,Joaquin Local: Health District. <br /> r��•�: 2?�5-­X70- <br /> JOB ADDRESS/LOCATION �"' . ® �i CENSUS TRACT " - <br /> Owner°s Name T ! Phone <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW,WELL '/ / DEEPEN -/ / RECONDITION /_/ DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAI / / PUMP REP EMENT / <br /> Other "/ / ` <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing s ; <br /> Domestic/public Driven Gauge of Casing i <br /> 1----Iirigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information " <br /> PUMP INSTABUATIONZ Contractor I <br /> Type of Pump H.P. ' 0 <br /> PUMP REPLACEMENT: f / ' State Work Done <br /> �JLUEPAIR: 4.--,/�/ y, State-Work Done <br /> DFfiTRUCTION" OF WELL: Well Diameter T -- - Approximate Depth <br /> Describe Material and Procedure <br />�i <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 /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information,is "true to the best o my knowledge and belief; <br /> . j <br /> ,. SIGNED V TITLE <br /> (DRAW PLOT .PLAN ON REVERSE SID } <br /> FO E ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMASENTS: <br /> PRASE II GROUT INSPECTION Peg I I/ NAL INSPECTION <br /> INSPECTION BY DATE INSP TION B DATE �- z <br />{ CALL FOR-A GROUT INSPECTION- PRIOR-TO-GROUTING AND FINAL INSPECTION. i <br /> E H 1426 5/731M <br />