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FOR OFFIC USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3- 5`�G <br /> THIS. PERMIT EXPIRES I YEAR FROM DATE ISSUED ' <br /> 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 /> JOB ADDRESS/LOCATION ... . , . <br /> • CENSUS TRACT } <br /> Owner's Name _ <br /> Phone �f - <br /> Address <br /> City _ <br /> Contractor's Name <br /> License # /Z4,>ZVPhone <br /> TYPE DFWORK (Check): NEW WELL �-7 DEEPEN / / RECONDITION /_7 DESTRUCTION 1'-7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / /? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE <br /> Industrial Cable Tool <br /> Domestic/private — pia, of Well Excavation \ <br /> Drilled Dia, of Well Casing alt— <br /> Domestic/public Driven Gauge of Casing w ' <br />_ Irrigation Gravel Pack —�� — _ <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR* / / State Work Done <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth ! <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> end 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 /> FELL-DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.*formation is true to the best of my knowledge and belief. <br />'�IGNED <br /> TITLE ' <br /> (DRAW PLOT PLAN ON�REVE�R�SSE�_ IDE <br /> RASE I <br /> FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE L 7 <br /> 1 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY c <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7179 im 1 <br />