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F - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . OI'"ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �W Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No �GU <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 a p icationis de in compliance with San Joaquin <br /> County Ordinance No. 1862 le g n Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION t NSUS TRACT <br /> Owner's NamePhone <br /> Address ACity 1 _ <br /> Contractor's Name License #� hon <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN J / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INST CATION J / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LIMES PIT PRIVY <br /> SEWAGE DISPOA4KFIELD CE POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATJPNS <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 Informatia <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFRTRUCTION 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 f knowledge and belief. <br /> SIGNED TITLE <br /> DRA PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY /d DATE <br /> ADDITIONAL COMMENTS: 8 <br /> PHAS Z GROUT INSPEC ON PHATE III/FINAL INSPEC'TI0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. a <br /> E H 1426 5/731M <br />