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SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif:, <br /> Telephone; (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Permit No. ;�2 <br /> 4 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 /> F <br /> JOB ADDRESS/LOCATYON QT CENSUS TRACT <br /> Owner's Name- G <br /> Phone ' <br /> Address g /are City Sfax FiiPfll�C�s�� <br /> Contractor's Name S, License <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN. /? RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> f PUMP INSTLATION /I PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia, of Well Excavation t <br /> Domestic/private Drilled Dia, of Well Casing P <br /> Domestic/public i Driven Gauge of Casing <br /> .. Irrigation Gravel Pack Depth of Grout Seal <br /> Other Ro.taxya F. Type o,f Grout _.._ <br /> Other Other Information n <br /> r <br /> �F <br /> PUMP INSTALLATIONS Contractor - <br /> Type of Pump H.P. <br /> } t' `: .x.,71«•' 4 <br /> PUMP REPLACEMENT: /L/�3State Work Done c 40 <br /> i <br /> ''PUMP REPAIR_:_. .,i .�, <br /> //"'"State.13o`rk'D`orie- <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 San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the 'we.11 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �w► .. I • . <br /> PHASE II GROUT INSPECTION ter"" P II INAI, INSPECTION ,} µ <br /> INSPECTION BY DATE INSPECTION X DATE <br /> CALL FOR A GROUT .INSPECTION., PRIOR TO GROUTING AND FINAL INSPECTION. <br /> k E H 1426 <br />