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SAN J6t1QUIN LOCAL HEALTH DISTRICT <br /> F'OI. OFFICE USE: 1601 E. Hazelton Ave: , -Stockton, Calif. F <br /> Telephone: ,,-(209) 466-6781 1 <br /> APPLICATION FOR WELL,.99NSTRUCTION 07 PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIR l R FROM DATE ISSUED Date Issued <br /> . , . (-Com`lete In Triplicate,) �� I <br /> P p , <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 witW San Joaquin <br /> County Ordinance No,1562 and the Rules and Regulations of the San Joaquin Local Heal,¢th District-, <br /> JOB ADDRESS/LOCATION / -� /�Gt G � CENSUS TRACT . <br /> Owner`s Name Phone <br /> ,Address 0 City . <br /> i <br /> Contractor's Name /_� � ►'l/V�- ..f _QJ� / License # Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN RECONDITION RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' I <br /> r <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. � r' <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 UPAIR: / / State Work Done <br /> X-gTRUCTION OF WELL: Well Diameter ^/Pi Approximate Depth - <br /> Describe Material and ProcedureIf ;t o <br /> I hereby agree to,.comply..with 1 laws and egulations of the an oaquin Deal Healt District <br /> and the State of Ca7:ifoini"'pertaini.ng to or. regiflatiag well "construction. Within FIFTEEN-DAYS � <br /> after completion of my work on a new well, ..I,w3il1'°fi•rnish the San Joaquin Local Health District a 1 <br /> WELL DRILLERS REPORT of .the well, and notify the'm`b'efore putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED kt _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) — <br /> FOR DEPART NT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED .BY DATE -� <br /> ADDITIONAL. =M; MNTS: <br /> PHASE II GROUT INSPECTION P III INAV-J- NSPECUCW <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROUT- INSPECTION -PRIOR TO.,GROUTING AND FINAL INSPEC N. <br /> E H 1426 5/731M .. <br />