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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r10£. OIIICE USE: v 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 construk-t <br /> .end/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 /> ^ r� <br /> JOB ADDRESS/LOCATION _A �ZI S R CENSUS TRACT <br /> Owner's Name '3t L I q be S C-A t4 r C Phone to S 3 d <br /> Address City <br /> Contractor's Name ����,, / -� Re License # Phone - �55g-2_ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN f / RECONDITION /_/ DESTRUCTIO <br /> ALN <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TP-�K SEWER LINES PIT PRIVY AIA <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 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: State Work Done <br /> DF-,TRUCTION OF WELL: Well Diameter , Approximate Depth Ct4l kn o tj-vN <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 /> informati is tru to th best of my knowledge and belief. <br /> SIGNED � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PiASE I <br /> APPLICATION ACCEPTED BY DATE Z� 7 <br /> ADDITIONAL CO Lti.�NTS: <br /> PHASE II GROUT INSPECTIONPHA �II/gFAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E II 1426 5/731rt <br />