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APAI L9 70 Yo t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT /z �+ <br /> L'0T:OFNICL; USE: 1601 E. Hazelton,Ave. , Stockton, Calif. <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatioa 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 an the.-Rules an Regulations of the Sart Joaquin Local Health District. <br /> 00 <br /> JOB ADDRESS/LOCATION ,$ � CENSUS TRACT <br /> y <br /> Owner's Name Phone <br /> Address <br /> City ' <br /> Contractor's.,Name License' Phone <br /> TYPE OF WORK (Check) : NEW WELL j J DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / f PUMP REPAIR / / POMP REPLACEMENT /7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC T&NK SE14ER LINES PIT PRIVY <br /> SE14AGE 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 11: Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i� Gravel Pack Depth of Grout Seal. o •��� <br /> Other . . . .�_.,._.��...�.�,_,._ <br /> 4. Rotary Type of Grout44.4-4 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump M.F . <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP TtEPAIR: / J State Work Done <br /> t <br /> .DFCTRUCTION 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 /> TELL DRILLERS REPORT' o€ 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 /> 3 <br /> SIGNED e,,pA TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE 12 -41-2:3 <br /> ADDITIONAL COVYIENTS: <br /> PHASE II GROUT INSPECTION PHASE ITT/FINAL INSPECTION <br /> INSPECTION BY 6W DATE 12-.q-2a INSPECTION BY OAe, .DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. G3 j <br /> E H 1426 <br /> 5/731M 731M -4 <br />