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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. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued <br /> (Complete In Triplicate) l <br /> Application is hereby made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. This application 'is made in compliance'lwith San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regula i ns f the' S Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �. ;Fd C ' CENSUS TRACT 4 <br /> Owner's Name �m <br /> J Phone <br /> Address _ �c� _ ,t'J .._.. City e__ <br /> a <br /> Contractor's Name License # / <br /> hone X <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /? RECONDITION /-7 DESTRUCTION /-711 <br /> PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: , SEPTIC TANK SEWER LINES PIT PRIVY ul <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <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 '? <br /> g Gravel Pack _ .....Depth of Grout ��Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONa Contiractor <br /> Type of Pump w ✓ ¢ H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> - 1 <br /> PUMP REPAIR: <br /> /yQ State Work Done 4c-,) <br />.RESTRUCTION OF WELL: .Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 ledge an belief. � a <br /> t <br /> SIGNS TLE <br /> (DW PLOT PLAN ON RE SE SIDE -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DA E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE:„ �- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ;w <br /> E H 1426 7172 1M <br />