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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , y��"` C S �' Y�,.�G, CENSUS TRACT <br /> _,,.._.,,_.,L .,.,_,,.,. .....T..._.. <br /> Owner's Name Phone �afds"�? <br /> Address City / <br /> Contractor's Name � �� -P i" QV License # _� Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /? <br /> PUMP INS AL ATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /_ <br /> Other ./—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 5�j_ SEWER LINES PIT PRIVY <br /> S WAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER vl <br /> INTENDED USE T E 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 h Rot Type of Grout <br /> Ot r Other Information <br /> PUMP INSTALLATION: ontra or <br /> Type of um H.P. <br /> PUMP REPLACE ENT: / / r t ork o <br /> PUMP UPAIR: / / State Do <br /> .DFgTRUCTION OF WE Well i eter \0 Approximate Depth <br /> De r' Materi 1. and ocedure <br /> I hereby agree to comply w' a 114s and regulations of °the San Joaquin Local Health District <br /> and the State of California pert ng 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 -TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY / DATE <br /> ADDITIONAL CO�DMNTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ► r � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTIWG AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />