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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601. E. Razel.ton Ave. , Stockton, Calif <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-5 3 S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �{_ 3 <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 Sax Joauiri <br /> County Ordinance No. 1962 and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� -CENSUS TRACT , <br /> Or <br /> Phone <br /> f wners Name � <br /> Address � - City <br /> Contractor'''s Name _License �� 3 Phone ��- 9� S <br /> e <br /> TYPE OF WORK (Check): NEW WELL /_/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION J f PLW REPAIR '/—/ Pi3MP REPLACEMENT <br /> Other ./ <br /> F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 /> i 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 /> f <br /> �. PUMP INSTALLATION: Contractor v <br /> I� Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Don <br /> PUMP `tEPAIA: j j State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter _ -- Approximate Depth <br /> Describe Material and Procedure <br /> �i <br /> l <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j 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 belief. <br /> y SIGNED TITLE <br /> (BRA LOT(/PLAN ON REVERSE SIDE) <br /> E . OR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION ACCEPTED -BY4 -,-4- M�__) <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G5PfCTIOVrPHAS SPECTIGX <br /> INSPECTION BY LAATE INSPECTION BYE <br /> CALL FOR A GROUT INSPECTION PRTOP. TO GROUTING AND FINAL INS T <br /> 5/731X <br />