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c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haxel,ton Ave. , Stockton, Calif. e <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR'..PUMP PERMIT '" Permit No. <br /> THIS PERMIT EXPIRES I: Y'EAR FROM DATE ISSUED Date Issued - 'r 7S <br /> (Complete In Triplicate) <br />,Application is hereby- made to the San Joaquin Local Health District for a permit to construct <br />'a\nd/or install the work '�kerein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI.ON, �IXiz__&aft��ENSUS TRACK <br /> .k <br /> a I <br /> Owner's Name Phone <br /> Address City I! <br /> Contractors Name cense # I Phon 9-3-3 <br />-TYPE,OF WORK- (Che ck):---IVEW-WELL- f=/`DEEPEN / I RECONDITION%_7 DESTRUCTION/_74 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <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 /> Domestic/public � Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ I� <br /> Other Other Information IM <br /> I <br /> PUMP INSTALLATION: contractor <br /> Type of Pump H.P'. <br /> I� <br /> PUMP REPLACEMENT: / -/ State Work Done <br /> I` ll <br /> PUMP REPAIR. / V State Work Done J� <br />,DESTRUCTION 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 Cali€orflia 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 Heath District a 1 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above i <br /> information is true to tte best of my knowledge and belief. <br /> SIGNED TITLE <br /> If (DRAW PLOT PLAN ON REVERSE SIDEII• <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . r <br /> APPLICATION ACCEPTED BY f AT <br /> ADDITIONAL COMMENTS: <br /> /� J' <br /> PHASE II GOUT INSPECTION PHASE III FINAL INSP 'TIO <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> k <br /> CALL FAR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> A E H 14'26 ff 7/�I2 1M <br /> q <br /> J <br />