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SAN JOAQUIN OCAL HEALTH DISTRICT <br /> 0FrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No.� f� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issucd --7 <br /> (Complete In Triplicate) f <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 3oaquW <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> ,� <br /> .TOB ADDRESSILQCATION C1� CENSUS TRACT t <br /> a-) (� r <br /> Owner's Name Phone <br /> f <br /> Address City <br /> 4 <br /> License � ? Phoneg� <br /> Contractor's Name � � - f. . <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/—/ RECONDITION_! I DESTRUCTION /7 <br /> PUMP INSTALLATION / / PLS' REPAIR / / PUMP REPLACEMENT /_7 <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 U <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 @a - J <br /> Other Other Information <br /> S <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done _ <br /> DF TRUCTION <br /> OFWE L: 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 /> E 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 /> i WELL DRILLERS REPORT of .the well and notify them before putting, the well in use. The above <br /> finformation is true to the best of my knowledge and belief. �[ <br /> SIGNED eA TITLE %1�Z2:22 Gl! <br /> t (DRAW PLOT PLAN ON REVERSE SID <br /> FOR'DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY [% ATE S/ -- <br /> ADDITIONAL COMMENTS: G1.swti, �- - <br /> P SE II GROUTINSPECTIONPHASE-III/FINAL INSPEC <br /> INSPECTION BY DAT ^� INSPECTION BY DATE O <br /> CALL FOR A•GROUT INSPECTION PRIOR TO GROUTING AND FINAL ,INSP ION. CD <br /> 5/731M 1 <br />