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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t t� . OI FICE <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> e-�" - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'4� j�u/ <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J ' lY 7 L � ( Uyti CENSUS TRACT <br /> 4 <br /> Owner's Name � ' Phone <br /> Address 111194 .y,��Citi1 � � l /�,► __ City <br /> Contractor's Nam ,` n U� -' Licensei� *-T Phon c� <br /> TYPE OF WORK (Check): NEW WELL Rl- DEEPEN /-7 RECONDITION_/ / DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAAK 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 1141 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing fill <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 A.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP UPAIR: /—/ State Work Done <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 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 is true to the best of my knowledge and belief. <br /> SIGNED {- i TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IC <br /> APPLICATION ACCEPTED BY c DATE <br /> ADDITIONAL COMMENTS: <br /> PIASE I GROUT INSPECTION P I FINAL INSPE ION <br /> INSPECTION BY DATE 1 INSPECTION BY DATE <br /> CALL YOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INSP N. <br /> E n 1426 5/731M <br />