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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. "OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED Date Issued -3-Z <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 R les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name V PhoneJ -- <br />} Address city - ,M-. <br /> Contractor's Name frit License'# Phone ' <br /> TYPE OF-WORK (Check): NEW WELL I / DEEPEN '/ / REC0NDITION YC DESTRUCTION /-j <br /> PUMP INSTALLATIONI J PUMP REPQ.IR / PUMP REPLACEMENT <br /> Other ,r <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 tS: <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. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. .� <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP UPAIR: J / State Work Done <br /> ,DF�qTRUCTION OF WELL: Well Diameter Approximate Depth F <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 /> 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 /> E <br /> SIGNED �� TITLE <br /> (DRAW PLOT PLAN ON REVERSES E) <br /> f I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` _ r DATE 3 }� <br /> ADDITIONAL CONRC-NTS: <br /> PRASE II GROUT INSPECTION PHASE II�YFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA 4 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />' r - 1 r- t <br />