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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 CONSTRUCTION• OR PUMP PERMIT Permit No. <br /> VO4THIS PERMIT EXPIRES 1 YEAR FROM DAVE ISSUED Date Issued Z_ 21- <br /> (Complete <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 ,5D CENSUS TRACT " <br /> Owner's Name49j/T/�` � �� �� 7" f• s� G��?d 1 D Phone "� <br /> Address W�77 — ,City <br /> ,� I <br /> Contractor's Name <br /> License # 6, .x`13 Phone <br /> E �;rn eta aJLG �?- (^� <br /> TYPE OF WORK (Check) : NEW-;-WELL/ / DEEPEN/ / RECONDITION /7 DESTRUCTION- /7 <br /> PUMP INSTALLATION / / PUMP REPAIR.'/ / PUMP REPLACEMENT /7 <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of; Casing O <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 H.P. <br /> i <br /> PUMP REPLACEMENT. / / State Work Done <br /> P1�r t <br /> UMP REPAIR: State Work Done . <br /> ,DESTRUCTION 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 /> 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 /> SIGNED - C TITLE <br /> (DRAW PLC rL ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II R T INSPECTION' PHASE III/FNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 1M " <br />