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'.�,,SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.;O_FFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone:, (209) 466-x6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77'1,201 <br /> THIS PERMIT EXPIRES 1 YEAR-FROM.DATE ISSUED Date Issued ", <br /> ' (Complete In ,Triplicate) <br /> AppiicatiAiI_is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or fndtall-the work herein described. This application is made in compliance with Sant Joaquin <br /> County Ordinance .No. 1862 and theRulesand,Regulations of the San Joaquin Local Health DigCrict: <br /> JOB ADDRESS/LOCATION C I CENSUS TRACT , <br /> Owner's Ndme DAA Phone <br /> Address 016r- <br /> Contractor <br /> City . . — <br /> Contractox's Name _ License �� Phan <br /> i <br /> i <br />'; TYPE OF WORK (Check): NEW WELL DEEPEN '/ / RECONDITION I I DESTRUCTION <br /> PUMP INSTALLATION /, / PUMP REPAIR / ! PUMP REPLACEMENT <br /> Other - � — <br /> il.i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 /> OtherRotary Type of Grout <br /> Other Other Information <br /> j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPTiACEMENT: { / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFgTRUCTI�ON 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 true to the best of my knowledge. and belief. <br /> SIGNED TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY w <br /> ADDITIONAL COMMENTS: ;:u ",. /7PHOS II GROUT INSPECTION PHOS III/FINAL INSPECTION <br /> INSPECTION BY Y DATE INSPECTION BY DATE <br /> ' CALL-FOR-A QUT-6INSPECTION PRIOR .TO GROUTING- AND-FINAL- INSCTION. <br /> I E H 1426 a 547 - <br />