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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l�F� ICE UAE: 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 /> and/or install the work herein described. ' This application is made in compliance with San Jaaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the an Joaquin Local. Health District. <br /> A <br /> JOB ADDRESS/LOCATION <br /> (CENSUS RACT <br /> Owner's Name �AV��y�l.�� Phone .���'- <br /> Address Z 9-5- <br /> 7 (/ City <br /> Contractor's Name License 0 Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /- RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR j / PUMP REPLACEMENT j= <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TAi1K �,�_ 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 _ g Rotary Type of Grout <br /> Other. Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - _ <br /> PUMP REPLACEMENT: j j State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />'i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f 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 toe 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 /> F information is true to the best of my knowledge and belief. <br /> t �} <br /> SIGNED L✓ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> d PHASE I <br /> APPLICATION ACCEPTED BY DATE , �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTINSPECTION PHASE IS /FINAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE/9,-;E ,, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - / 7 <br /> E H 1426 5A93 <br />