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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif, - <br /> Telephone: (209) 466"6781 I <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES .1 YEAR FROM-DATE 'ISSUED Date Issued -Z- <br /> (Complete 'In Triplicate) <br /> ApplicationApplication is here y 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-.Reguiations.,of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D - V `11 CENSUS TRACT <br /> Owner-'s Name, ` ,(, ; ; a. ' Phone ' 4 <br /> Address Cit e ` <br /> Contractor's Name License # n y <br /> �6S`7L Phone <br /> TYPE OF WORK (Check): NEW WELL '/—/ DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /- f <br /> PUMP INSTALLATION / / PUMP REPAIR '/)U PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 42. SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL 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 <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT., / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sari, 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 /> I <br /> r <br /> SIGNED � f TITLE <br /> (44�W PLOT PLAN ON REVERSEtSIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION _ PHASE III F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 072 IM <br />