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a SAN JOAQUIN La A 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. l�o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <br /> (Complete In Triplicate) <br /> Application is hereby'maide to the Sari Joaquin Local Health District 'fors 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,Loca1 Health District. <br /> JOB ADDRESS/LOCATION 54 CENSUS-TRACT <br /> Owner's Name - 3, � . Phone <br /> Address 4? 6f ..:�0 Z - City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENLL/�/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /T/ PUMP REPLACEMENT /? <br /> Other /_7 <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/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> f 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 /> and' Procedure <br /> P. <br /> ' I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j 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 <br /> i. WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above O <br /> f information is true to the best of my knowledge and belief. <br /> SIGNED { TITLE <br /> (DRAW PLOT PLANADN REVERSE SIDE <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> z2Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION,. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 717z 1M W <br />