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XJ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> #Tf'0:'.•:•Oi FICE USE.- - 1601 E. Hazelton Ave. , Stockton, Calif. <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 /p <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 Health District. , <br /> .JOB ADDRESS/LOCATION � � ��� �t�,t�,ea.a,. ��A9�.� �.,�. CENSUS TRACT <br /> Owner's Name � �. Q,� j Phone <br /> Address _ ' S �� - - - = -- - City. # <br /> Contractor's Name ,,(� ,� License # 3 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ % DEEPEN '/ / RECONDITION l I DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other / — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (k, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Al <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 /> i <br /> 7x <br /> PUMP REPLACE�TSNT: { / State Work Done JQ fir+ a• <br /> PUMP 'REPAIR: / % State Work Done.- <br /> — <br /> Y <br /> .DFATRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San ,Joaquin Local Health Distric <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 Distric <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. F <br /> SIGNED TITLE ,f <br /> (DRAW PLAUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY 'a 4 f,L� ) DATE F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT- INSPECTION PRIOR TO. GROUTING AND FINAL INSPECTION. <br /> _ _- E H 1426. 5/731M <br />