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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOI.:OP7ICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3�� <br /> 1 ('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 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAfEO CENSUS TRACT <br /> Owner's Name <br /> I <br /> Phone <br /> Address <br /> City <br /> Contractor°s Name License ��� phon <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTLATION / / PUMP REPAIR/� PUMP a <br /> / REPLACEMENT /� <br /> Other -/_7 <br /> DISTANCE TO NEAREST: SEPTIC TANS: SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation (1 <br /> Domestic/private V Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing � p <br /> Irrigation Y Gravel Pack Depth of Grout Seal <br /> Other V Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: � - <br /> tate Work Done <br /> PUMP `tEPAIR: / / State Work Done � <br /> i <br /> DRcTRUCTIQN 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 r , A <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED .BY o'�/—A,50—�. DATE �` — 7b//' <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY - INSPECTION BY DATE 3-3- 7 d <br /> CALL-FOR-A-GROUT-INSPEC ON PRIOR TO .GROUTING AND FINAL INSPECTION. ' <br /> E_1I 1426 <br />