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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOL:OPFIICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/,!_�l�y_4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2-6e,0-q <br /> Application is hereby made to the San Joaquin Local Health District for a permit t6 construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance .No: 1862 aiid the Rules and Regulations .of the San Joaquin Loc <br /> latl/ �lea1 th District. <br /> r '. �. f•c� ' c � Y� STJ 'k'RACT <br /> JOB ADDRESS/LOCATZONv <br /> Owner's Name :Q'- �1 S / /� S '� Phone <br /> Address City ' . <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL/V�—_DEEPEN �/ / RECONDITION %// DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /7 <br /> 0thcr / I I S <br /> -- A �- �� N <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> d% <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 /> r � <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / i State Work Done <br /> 7---Stam-Work Done'' �� . �. -.�..N ...:: ..� �--• <br /> it <br /> DRqTRUCTION OF WELL: Well Diameter Approximate Depth <br /> P 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 t1ii well and notify them before putting the well in The above <br /> information is true to the .be.Bt of knowledge and belief. <br /> TITLE <br /> SIGNED <br /> a (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> 05 <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATE -tl' <br /> ADDITIONAL COMMENTS: '. <br /> PHASE II GROUT INSPECTION. PHAS I NAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> j - CALL FOR-A-GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION.. � <br /> H 1426 5/731M <br />