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_ SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> SOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na.� �L�� <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 /> 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 Regula ons of the San Joaquin Local Health District. <br /> JOB ADDRESS jLOCATZON4T "yy ,4K-1ENStTS TRACT• <br /> Owner's Nam hone <br /> Address City <br /> Contractor's Name cense- Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN I / RECONDITION/_/ DESTRUCTION / <br /> PUMP INST TION / f PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TEAKR LINES T PRIVY <br /> SA <br /> SEWAGE DISP F D CESSPO SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private gilled 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 /> Type of Pump H.P. <br /> PUIV REPLACEMENT: / / State Work Done- <br /> PUMP <br /> one_PUMP REPAIR: / / State Work Done <br /> ,DFcTRUCTION 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 i true to the b of myknowledge and belief. <br /> SIGNED � TITLE ' <br /> (DAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Ara __ __ DATE • f' '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 731st <br />