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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> COI.:OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _7 y e&7� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <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 /> JOB ADDRESS/LOCATION (VOIS CENSUS TRACT ; <br /> Owner's Nasse ear FR,4me Phone -- k <br /> Address E,gm P City <br /> Contractor's Name riS - - License #A22&g Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN J / RECONDITION /_{ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK W? SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD 135' CESSPOOL/SEEPAGE PIT --- OTHER — w <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r Domestic/private Drilled Dia. of Well Casing (o <br /> Domestic/public Driven Gauge of Casing _•/2 <br /> Irrigation - - - Gravel Pack Depth of Grout Seal v <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 4 <br /> PUS' INSTALLATION: Contractor <br /> Type of Pump H.P. _J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP U-PAIR: / / State Work Done <br /> ,DF9TRUCTION 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 well and notify them before putting the well in use. The above <br /> information is t e t the best of my knowledge and belief. <br /> ` F <br /> SIGNED TITLE <br /> (DRAW PIAT PLAN ON REVERSE SIDE) s <br /> FOR DEPARTMEN USE ONLY <br /> PHASE I <br /> APPLICATION_ ACCEPTED BY DATE. <br /> ADDITIONAL CO:0IENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -IY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN5 TION. <br /> r r 1494 5/731M � <br />