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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ro -.00} USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' ' I�FSTelephone: (.209) 466-6781 <br /> ■ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �fd � (Complete In Triplicate) <br /> Application is hereby made, to the San Joaquin Local Health District for Wiz- 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 /> C <br /> JOB ADDRESS/LOCAT N�_ S S TRACT - <br /> Owner's <br /> RACT Owner's Name /. U Phone <br /> Address040 <br /> City <br /> w Contractor--'_s Name.. - License-. .—.: -. phone - <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/ / RECONDITION / / DESTRUCTION 1-7 Q <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other' /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINS PIT PRIVYC <br /> SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE PIT OTHER <br /> INTENDED USE 'HYPE OF L CONSTRUCTION SFECIFICATIONS <br /> In trial I able Tool Dia. of Well Excavation <br /> omestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout � �' i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> T e of Pump <br /> ump H.P. <br /> PUMP REPLACEMENT: ,/, / State Work Done <br /> PUMP tEPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter ` <br /> 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 /> informat*345 to the best f my knoialedge and belief. <br /> SIGNED TITLE . <br /> CDRAW PLAN ON REVERSE SIDE) <br /> PHASE I F DEPARTMENT USE ONLY <br /> ��� f <br /> APPLICATION ACCEPTED ,BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ - INSPECTION BY DATE - 2A-- - ' <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. i1 <br /> E It 1426 e i-7 n,_. r'T� <br />