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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 6r.".OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />{ PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7yL <br /> . (Complete In Triplicate.) <br /> Application is hereby mde to the San Joaquin Local Health District for a permit to construct <br /> and/or install: the work erein described. ' This application is made in compliance with Sane Joaquin <br /> County Ordinance No. 186 an the Rules and Regulations of the San Joaquin Local. Herlth District. <br /> �30 <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT ' <br /> Owner's Name I Phone <br /> Address ,� city ' ' <br /> x <br /> Contractor's Name License #111rf <br /> �2 1. Phan `,� .� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLW 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUTT INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP <br /> .P. .PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> h ,DF-TRUCTION 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 /> f after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'t 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 /> SIGNEDTITLE <br /> ° (DRAW 'PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I u <br /> APPLICATION ACCEPTED .BY . .------- DATE g�J.1 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION P SE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A QUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 q/7 i im <br />