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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf. OFIICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ARPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /fes <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ; -,P, <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 Saiz Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t'j Lt'i. f��✓LN_ .r)- r� ENSUS TRACT <br /> Owner's Name Phone <br /> Phone <br /> Address <br /> Cit ' <br /> Contractor's Name License Phan <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /—/ DESTRUCTION /-J <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �yA <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ��+) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V`t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �1 Domestic/private KDrilled Dia. of Well Casing <br /> TT 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 /> 4 Type of Pump H.P. <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> r _ <br /> PUMP 'ZEPAIR: / / State Work Done <br /> 3 <br /> DF--TRUCTION 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 iay 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 />�i SIGNEDz TITLE <br />' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _-2 —v '2,e,- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/FINAL INSPECTION <br /> INSPECTION BY DATE 2 -�-7� INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. <br /> E H 1426 5/731M <br />