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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF_ Or PI i1, USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 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 to the San Joaquin Local Health District for a permit to const l iii.t; <br /> Z,,nd/or install the work herein described. , This application is made in compliance with Sant Joaquin <br /> County Ordinance No. I.S62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A t 0 CENSUS TRACT <br /> Owner's Dame L'� Phone <br /> / <br /> Address ' 'r �: ' ' :'�!�� City i <br /> Contractor's Nanie t License �� ,' Phone � 4V <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION V/-7 P�1MP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMEN <br /> other <br /> DISTANCE TO NEAREST: SEPTX TSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I:N`EINT)ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestzc/private Drilled Dia. of Well Casing <br /> Domcstic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> other Rotary Type of Grout <br /> Other Other Information <br /> Pi;ix`P INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> L)U�T REPLA Ch,!1I:i3T: / / State Work Done <br /> PUMP 'REPAIR: /�/ State Work Done <br /> DFgTRU'CTION Or WELL: Well Diameter !(/ Approximate Depth <br /> Describe Material and Procedure F <br /> I i�creby a-ree to coriply with all laws and regulations of the San Joaquin Local Health District <br /> quid the State of Cali-fornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> al ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :'LL 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 /> S I G N R D TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> APvLICATION ACC;'=ED BY DATE <br /> ADDITIONAL COI,2ii'NTS: _ <br /> PLASE II GROUTINSPEC' ION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY D E - 7�, <br /> CALL FOR A GROAT INSPECTION PRIOR TO GROU'T'ING AND FINAL INSPECTION, uif� <br /> Z 111 1426 5/731M <br />