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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 /> PLICATION FOR WELL CONSTRUCTION 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. Thisapplication 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 ADDRESStUMATI*N 7 j CENSUS TRACT .� <br /> Owner's Name ,` .)hone <br /> Address Sa City . <br /> Phone 7 <br /> S �. <br /> Contractor's Name !i 1? License <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_ 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 ,_ys Cable Tool Dia. of Well Excavation ' <br /> L--Domestic/private ° ' Drilled Dia. of Well Casing <br /> Domestic/public `Driven Gauge 'of Casing Z. <br /> Irrigation .-�'� Gravel Pack `Depth of Grout Seal IV ohP ' <br /> Other Rotary Type of Grout _ <br /> + Other . ' Other Information <br /> PUMP INSTALLATION: =' ContractorS <br /> Type of Pump '' H.P. <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> G <br /> PUMP REPAIR: / State Work Done ✓ u <br /> T' r <br /> .pESTRUCTION 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 i TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE '5�z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS C ION PHAS I AL INSPEC N - <br /> INSPECTION BY DATE INSPECTION BY DATE �-- <br /> CALL FOR A GROUT INSPECTIONPRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ?/72 U�) <br />