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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �..FO ..OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: <br /> .. (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 /> f 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 /> j <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> f{, Owner's Name Phone <br /> sA e4 <br /> Address <br /> �* City <br /> Contractor's Name Licensef �k'hon <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 'INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria]. Cable Tool Dia. of Well Excavation <br /> Domestic/private XDrilled Dia. of Well Casing <br /> Irw Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel, Pack Depth of Grout Seal <br /> Other Rotary Type of Grout or <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r PUMP '?EPAIR:^. � 17 State Work Done <br />' <br /> DF"CTRUCTION 4F_...__.. ..... . 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 /> WELL DRILLERS" REPORT of .the well and notify thein before putting the well in use. The above <br /> information_ is true to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE <br />: (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> a_ PUASE I <br /> APPLICATION ACCEPTED .BY DATE . <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INS CTION <br /> INSPECTION BY aRt5�, <br /> SP TI.9N BY DATE <br /> CALL FOR A GROUT INSPECT' To INC }7 <br /> R N lA7F C /71-vw <br />