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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 #, <br /> APPLICATION FOR WELL CONSTRUCT% ION 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. 1862;`and the Rules and Regulations of the San Joaquin Local Health District. <br /> 11 <br /> JOB ADDRESS/LOCATION 7 5-e- c ff Qh <br /> CENSUS TRACT c <br /> Owners Name Phone <br /> Address � <br /> City <br /> Contractor's Name <br /> LiCensAp 7/ Phone �C � <br /> V <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INST LATION L/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 191j ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /#V OTHER <br /> INTENDED USE ,'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /SCJ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> ----- g Gravel Pack Depth of Grout Seal � <br /> Other C3`a �•'` t � <br /> Y' Rotary Type of Grout a <br /> Other Other Information <br /> a <br /> r <br /> PUMP INSTALLATION: Contractor All <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ; / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done .� <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> 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 /> _ f <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: 3 <br /> PHAS I�GRT NSPECTI N CNSPECTION BY PRASE III INAL INSPECTIONATE S� INSPECTION BY i DATE <br /> CALL FOR A GRO INSPECTION PR OR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 vv4/ ►�" <br />