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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FP-0F.-0I,lICE USE: 1601 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 /> anal/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 /> JOB ADDRESS/LOCATION 'g Co I�( A-T[rl CENSUS TRACT <br /> Owner's Name �(} h h �� �G Phone <br /> Address A, l!'TU City sc -d 64�� <br /> Contractor's Name &CLdl License # 113 L.S'Phone � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION %/ DESTRUCTION /? <br /> PUMP INSTLATION PUMP REPAIR 0 PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> 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 /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> �L <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP 'tEPAIR: / State Work Done d <br /> .DFgTRUCTION 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*eompletion 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 ofmv <br /> knowle"e an belief. <br /> SIGNED ITLE <br /> (D W PLOT PLAN ON ERSE SID _ <br /> FOR DEPARTMENT USE ONLY c <br /> APPLICATION ACCEPTED BY T, C DATE D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY kDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ., <br /> E H 1426 573ll� <br />