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--- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-r7oT,­d-i--i'iCE-u s-i.:: 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 ISSUEDDate Issued e--2 4-,PV- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to consLiuct <br /> and/or install tho 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 �, / Q CENSUS TRACT <br /> Owner's Name Phone <br /> AddressCity -7(2- <br /> Contractor's Name License # Phone "'7666696 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION A PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA;: KAL IESEWER LINES PIT PRIVY <br /> SEWAGE DISP SLD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Gi <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 <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: / f State Work Hone <br /> PUMP "REPAIR: /^/ State Work Done <br /> ,DFgTRUCTION 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 my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1 LL 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, <br /> i <br /> SIGNED ^ _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 2-t& <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY _ DATE - - <br /> ADDITIONAL =\DiENTS: V4 <br /> PHASE II GROUT INSPECTION PHASr III/ INAL INSPECTION � <br /> INSPECTION BY ^_� DATE INSPECTION BY DATE <br /> CALL I.-'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E 11 1426- - 5/731x[ <br />