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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOF. OFF.ICE ,USE: --: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l /S <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 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 /> JOB ADDRESS/LOCATION ,L ��r. . CENSUS TRACT <br /> Owner's Na Phone �� <br /> Address City <br /> Contractor's Name % License �Phongg <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / j RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / J PUMP REPLACEMENT I—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 "� a <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT; / J State Work Done �.� .. <br /> PUMP UPAIR: J / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> S 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 wellconstruction. 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 REP e well and notify .them before putting the well in use. The above <br /> information is -r est o my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY . � DATE �7 <br /> ADDITIONAL C01101ENTS: <br /> PHASE II GROUT INSPECTION PHASE II /F AL INSPECTION <br /> INSPECTION BY BATE INSPECTIONL�%�ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 11 1426 5/731M <br />