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SAN JOAQUIN LOCAL HEALTH DISTRICT h <br /> FOR OFFx"CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> fi Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <br /> c THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> A 'plication is hereby made -to-'the San Joaquin Local Health District for a permit to construct <br /> sand/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 /> t fir. .: ..:c�4- -- �►2 '�= 1, .�� e ! <br /> JOB ADDRESS/LOCATION `n CENSUS TRACT <br /> f. Owner's Name e f"e r r a Phone <br /> Address �� �K� "� / / -- -- City <br /> 4 Contractor's Name _ -- <br /> License # Phone <br /> k <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /? <br /> RECONDITION DESTRUCTION / -7 <br /> PUMP INSTALLATION /—/ PUMP: REPAIR X PUMP REPLACEMENT 17 <br /> Other <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 /> Dome stic/public Driven Gauge of Casing <br /> M Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> " <br /> PUMP REPAIR: State Work Done <br /> / / <br /> IRESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> LI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land 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 RE RT f the well and notify them before putting .the well in use. The above <br /> information is r e t� a st of my knowledge and belief. <br /> SIGNS <br /> TITLE' <br /> � {DRA PLOT PLAN ON REVERSE SIDET-_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> i ADDITIONAL COMMENTS: <br /> ~ <br /> PHASE II GROUT INSPECTION PHASE III FNSPECTI N <br /> 12 3— <br /> INSPEC -ION .BY, . _ DATE INSPECTION BY DATE 'G <br /> CALL FOR A GROUT' INSPECTION .PIRIOR,TO GROUTING ANDrFINAL�INSPEC ON. <br /> ".9 H 1426 s: <br />