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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a FOF.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued P 7X <br /> (Complete In Triplicate) <br /> t 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 trade 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 <br /> a CENSUS TRACT <br /> Owner's Name Phone <br /> Address .� u.+ City <br /> Contractor's Name ,� License Phone <br /> TYPE OF WORK (Check) : NEW WEL" DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> NS <br /> PUMP INSTALLATION / / PUREPAIR/ / PUMP REPLACEMENT /- <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK�� SEWER LINES PIT PRIVYr <br /> SEWAGE DISPOSAL FIELD,,, CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> --rte--- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing "CJ__rcrrr�C� <br /> -- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout r -.-- <br /> Other Other Information ..S;ee <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />` PUMP "z.EPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k 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 />'f 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 />€ #riformation 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 COMMENTS: <br /> PHASE II GROUT INSKECTION PHASE III/ INAL INSPECTION <br /> INSPECTION4BY DATE INSPECTION BY , DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> V. U Ibis r X70 .. <br />