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SAN JOAQUIN UCAL HEALTH DISTRICT <br /> FOF:OFFICE. USE: b 1.601 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 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 Joa uin Local Health District. ; <br /> JOB ADDRESS LOCATION TAl. /. I. e <br /> ADDRESS/LOCATION eve_ )d2 C' o CENSUS TRACT <br /> r G <br /> Owner s Name 91— Phone ( rjSp(a mox <br /> AddressG'rr!J'J /'IOP a City <br /> Contractor's Name ooh _ License #f�6��g Phone <br /> ��1 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ J RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTLALLATION j f PLUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK pC SEWER LINES lt�o — PIT PRIVY <br /> SEWAGE DISPOSAL FIELD IWI CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / g <br /> Domestic/private Drilled Dia. of Well Casing 51/1 X 12- <br /> Domestic/public <br /> 2Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel. Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout . 0 -e�-/e <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: f_1 State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFsTRUCTION 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 trill -furnish the San Joaquin Local Health District a j <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 /> i SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY DATE .{ — - <br />} ADDITIONAL COMMENTS: T <br /> PUASEti, GROUT INSPECTI N P I/FINAL INSPECTION 1 <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> CALL FOR UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L I7 Y V <br />