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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOF-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.' <br /> � ssya 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1p_,2�T-.3' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local .Heal.th 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name � � �..� ( License # Phone <br /> i <br /> TYPE OF WORK (Check); NEW WELL (( DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> i 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/privateµ Drilled . .Dia.. of. Well Casing <br /> DamesLLic/public Driven Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal (J <br /> Other x Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: State Work Done ' <br /> d <br /> ,DFCTRUCTION OF WEU: Well Diameter Approximate Depth F <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to .comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali.fornia�pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a neva well, I will furnish the San Joaquin Local Health District a ` <br /> WELL DRILLERS REPORT of .tlie'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 /> SIGNED <br /> _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � <br /> FOR/DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .'B zCr�?1 �re f DATE 141 <br /> ADDITIONAL COMMENTS <br /> PIM E II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY iDATE. 'INSPECTION BY RATEe 2,4 . 7 <br /> -CALL -FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. r / <br /> E H 1426 <br />