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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT.:OI FICE USE: 1601. E. Raxelton Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466--67$1 F <br /> "APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> II <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 Joaquin. <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local Ileal.th District. <br /> .TOB ADDRESS/LOCATION <br /> 9 c CENSUS TRACT <br /> Owner's Name Phone <br /> r <br /> Address City L I <br /> Contractor's Name License ��iJlPhone <br /> TYPE OF WORK (Check) : NEW WELL / �/ DEEPEN/_/ RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENT <br /> r. /� <br /> Othe / — <br /> DISTANCE TO NEAREST: SEPTIC TIUNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER Q� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `Ls <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 f <br /> Other X Rotary Type of Grout <br /> �lOther Other Information <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .H.P. <br /> PUMP'REPLACEMENT: / / State Work Done <br /> PUMP PAIR: / / State Werk Done <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> Lifter completion of my work on a new well, I will furnish the San Joaquin Local Health Distri t a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> f information is true to the best of my knowledge and belief. <br />` SIGNED TITLE " <br /> (PPAW PLOT PLAN ON REVERSE SIDE <br /> FZR DEPFP,RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B _ <br /> YaIn8VEG$��ION <br /> ' DATE, <br />` ADDITIONAL COMMENTS: <br /> P}IAS II PHASE I I FSEAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE – <br /> CALL FOR :A GROUT INSPECTION PRIOR TO- GROUTING AND FINAL INSPECTION. <br /> 7 IT 1Z19A 5/.731M <br />