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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /�7j 71 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> j JOB ADDRESS/LOCATION a/f <br /> . CENSUS TRACT <br /> Owner's Name <br /> ' Phone <br /> Address <br /> City <br /> Contractor's Name <br /> 0AJ ' ' <br /> License # .02j L)Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN� ��/� RECONDITION /_ SDESTRUCTION /`7 <br /> PUMP INSTALLATION 4? PUMP REPAIR <br /> Other /% // PUMP REPLACEMENT /� <br /> i <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK f� <br /> SEWER LINES PIT PRIVY <br /> k SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <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 Gravel Pack Depth- of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H'.p� <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP -REPAIR;- / Statse,Wbrk lone - - �- <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth wG <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin q n 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 /> l <br /> SIGNED <br /> TITLE <br /> 4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY _�,_.....__ � INAL INSPECT <br /> DATE INSPECTIONBY Uti DATE N <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION' <br /> EH 1426 . _ _. <br /> - - 7/7 1M -► <br />