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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' l'OF,.:�I'lICF: USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- "7-7 <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 / !. w � CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name C' License 4�,�j ,: QPhone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL °DEEPEN / RECONDITION ESTRUCTION /� <br /> PUMP INS' AL�TION PUMP REPAIR _/ PUMP REPLACEMENT /� N <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TAINK =1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> cit <br /> t S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing e;5'" <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C <br /> ` Other <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y — H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> k <br /> k DFRTRUCTION 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 /> J 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 /> 14ELL DRILLERS REPORT of the well. and notify them before putting the well in use. The above <br /> { information is trueto the best o my knowledge and belief. <br /> 1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -__ <br /> . FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> p INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � 7 ] <br />