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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR Pu-,v Pe- jykrT- pit No. <br /> THIS PERMIT EXPIRES _1_YEAR FROM DATE ISSUED Date Issued -7 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name , ` �: - �_ Phone <br /> amePhone <br /> City <br /> Address 4, <br /> License Phone,,,- �, ,i <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL �XT DEEPEN-/ RECONDITION DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPCSA1--f-TTELD CESSPOOL/SEEPAGEEPAGE PIT OTHER <br /> 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation —V1. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ........ <br /> Irrigation Cravel Pack Depth of Grout Seal <br /> Other y Rotary Type of Grout <br /> Zk Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> ---4-1-4�t , H P <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR. State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterialandProcedure <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I INSPECTION. 711 <br /> E H 1426 /72 1 <br />