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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOLOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. zi _z,cyY kj i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION aA <br /> CENSUS TRACT , <br /> Owner's Mame Phone <br /> AddressCity <br /> Contractor's Name License #l�C�Phoneo - a <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_/ RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other 1_7 — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool. Dia. of Well Excavation <br /> Domestic/private -- X 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: / / State Work'Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> ;DFgTRUCTION 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 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 /> SIGNED TITLEj}�y�,Q/�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) e� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II NAL WSPECTJON <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A -GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> r 11 l inr E� 177-1y <br />