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^n r. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OwFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Per <br /> Na: � _ <br /> THIS 'PERMIT EXPIRES- I YEAR FROM DATE ISSUED w 'Date issued <br /> (Complete In Triplicate) <br /> Application is hereby, made toi.the San Joaquin. Local Health District, for a permit Coconstruct <br /> and/or install the work herein described. This application is made in compliance with' San Joaquin <br /> And Regulations' of, .the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and' the `Rules <br /> 6`' CENSUS.TRACT <br /> JOB ADDRESS/LOCATION <br /> Owr►er's Name <br /> SGL] PhorV DL'C <br /> -�"V <br /> Address <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN /7 RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / — <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N <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 t, Other Information <br /> I PUMP INSTALLATION: Contractor vSL <br /> Type of Pump H.P. / O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - -- <br /> .IhPESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> f 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED ,sGLGC/ TITLE r ' <br /> ' (DRAW PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY 13 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS II /FINAL INSPECTION <br /> BY DATE INSPECTION By DATE <br /> CALL- FOR A GROUT INSPECTION PRIOR TO-GROUTING AND FINAL INSPECTION. 7J72 1M , <br /> E H 1426 <br />