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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOz..OI VICE USI:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby shade to the San Joaquin Local Health District for a permit to construct I <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 /> S7 <br /> JOB ADDRESSILOCATION �©/ .C-. <br /> CENSUS TRACT <br /> Owner's Name , <br /> Phone g , , r <br /> �`�f 3 1V <br /> Address �b / City, <br /> Contractor's (J f �' License 3hone"g'76 <br /> _ f <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN -/_/ RECONDITION / J DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR M PUMP REPLACEMENT /7 <br /> Other 17 <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 � f <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Iiia. 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 /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP "tEPAIR: /W State Work Done <br /> .DF44TRUCTION 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 ''eonstruction. 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 /> SIGNEDTITLE _ € <br /> (DRAW PLOT PLAN ON REVERSE SIDE} r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYECDATEJ;7� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPTI � <br /> F N IAIM <br />