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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POT, <br /> .OFFICE USE:: 1 .1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-67$1 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6,23�J <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. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name <br /> Phone <br /> Address <br /> City ' <br /> Contractor's Name � <br /> License lm nPhon <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 TALK SEWER LINES PIT PRIVY r <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 /> „ 1� <br /> 'Domestic/private I Drilled Dia. of Well Casing \ <br /> Domestic/public 1 Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other t y�Rotary Type of Grout <br /> Other Other Information ' <br /> ---- ._ <br /> Y <br /> f ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> �/ State Work Done <br /> r <br /> PUMP 'tEPAIR: <br /> /_7. State Work Done <br /> 4' f <br /> DESTRUCTION OF WELL: Well Diameter Approximate-bepth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District f <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 9 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDIT) <br /> PHASE' I FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE GRO DIISPECTION� 7� PHASE I INAL NSPECTION <br /> INSPECTION BY� INSPECTION BY / ATE <br /> CALL FOR-A-GROUT•INSPECTIXRIOR TO GROUTING-AND FINAL INSPECTION. F <br /> E H-1426 J_,___ <br />