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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FflF.:OFFICE . SE: 160,1 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,61 3- fit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' <br /> �7 <br /> i (Complete In-Triplicate) <br /> pl <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/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Namejr4&JA�L_., License IY2,(.j Phon <br /> r TYPE OF WORK (Check): NEW WELL A?f DEEPEN '/—/ RECONDITION /_/ DESTRUCTION f_7 <br /> PUMP `INSTALLATION / / PUMP REPAIR -/—/ PUMP REPLACEMENT /_ <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 i Cable Tool <br /> Dia. of Well Excavation <br /> � <br /> Domestic/private I KDrilled Dia. of Well Casing v <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout <br /> f Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: — <br /> / / !State Work Done <br /> ,DFgTRUCTION 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 x <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE"f <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROU INSPECTION PHASE II IN INSPECTION <br /> INSPECTION BY ATE - � INSPECTION BY DATE,2- ---z� f <br /> -� CAx.L-FOR A GROUT•INSPE ION- PRIOR GROUTING AND FINAL INSPECTION. (�(� I <br /> E H 1426 1" r- J-7,.__ <br />