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SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> F0r. OIFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR,WELL CONSTRUCTION OR PUMP PERMIT Permit -No. <br /> THIS PERMIT EXPIRES l 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 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 /> y I <br /> f 1a ^ u <br /> Owner's Name Phone �-J �.�-1,z - } <br /> Address i -, 7� City <br /> Ca�a'tractor`:s�Name License # l`"" Phone. -�' <br /> r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION f PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / DzZZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />'f 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 Depth17of-,Grout :Sea1 <br /> I Other' Rotary Type Lo : rout <br /> Other Other Information J <br /> PUMP INSTALLATION. Contractor e "'Y <br /> Typer`Pur4p _y H.P. ' <br /> PUMP REPLACEMENT: h/ <br /> N4.iState Work Done <br /> PUMP 'REPAIR: / - State Work Done . <br /> .DFgTRUCTION'OF -WELL.: T -Well Diameter -Approximate Depth <br /> Describe .Material and ,Procedure <br />} I hereby agree to comply with a'll~laws'and regulations of the San Joaquin Local Health District <br /> and-the:State-of-California .pertaining ,to ,.or regulating,well.�cons.truction.- 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 knJ ledge- and belief. y <br /> y SIGNED 1 yf <br /> as TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �fJ <br /> APPLICATION ACCEPTED $X �c,��� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY, DATE INSPECTION BY DATE S' <br /> '- CALL FOR-A-GRUT'7�-INSPECTION -PRIOR-TO GROUTING.AND FINAL INSPECTION. <br />' E 11-142.6 .5/731M j <br />