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G� 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOk <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL' 'CONSTRUCTION OR PULP PERMIT Permit No. 4J <br /> ' a <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate.) <br /> I <br /> P P I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <br /> and/or install the work herein described. ' This application is made in compliance with San, J'baquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health !,District. <br /> JOB ADDRESS/LOCATION •1 CENSUS TRACT " <br /> Owner's Name TA Phone <br /> Address o City . <br /> Contractor's Name s % Licens�®g Phon��� 6 <br /> TYPE OF WORK (Check): NEW WELL / ,✓ DEEPEN '/_—/ RECONDITION /_/ DESTRUCTION /-7PUMP INST LATION / -/ PUMP REPAIR /—/ PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p�,+ <br /> Industrial Cable Tool Dia. of Well Excavation G. <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 A Rotary Type of Grout <br /> Other Other Information: <br /> PUTT INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 2EPAIR: - _ _ / / - 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 thein before putting the well in use. The ab o e <br /> information is true to the best of my knowledge and belief. <br /> j SIGNED TITLE 2QJI� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORPARTMENT USE ONLY <br /> Al <br /> P14ASE I <br /> APPLICATION ACCEP DATE - <br /> t ADDITIONAL COI aMNTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ fqn,,., DATE /-;Z <br /> . CALL FOR A7 GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. G 0 <br />