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IS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1h <br /> �/ tockton Calif. <br /> FOR OFFI SE: 1601 E. Hazelton Av Ave. ,. <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/D <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to'the San Joaquin Local Health District for a pert►it to .th San Jo <br /> and/or install the work herein described. This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1662 and'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s C WA CENSUS TRACT <br /> Y <br /> S'S Phone F <br /> Owner's Name . <br /> City <br /> Address <br /> License # _74_46 <br /> � Phone 575 t <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION /�T DESTRUCTION / <br /> PUMP INSTALLATION / PUREPAIR / / PUMP REPLACEMENT' /7 <br /> MP <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY 3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER [n l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial � Cable Tool Dia. of Well Excavation <br /> Industrial <br /> Drilled Dia. of Well Casing <br /> DomeDomestic/public Driven Gauge of Casing '� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other ^ Other Information <br /> i <br /> PUMP INSTALLATIONo Contractor R.P. <br /> � Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work- Done <br /> �3.ESTRUCTION OF WELL: Well Diameter <br /> 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 /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> I ADDITIONAL COMMENTS: PHASE III/F INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BYEZ2�� <br /> TE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT 7J72 1M - <br /> E H 1426 - <br />