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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf. OFFICIO, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR-PUXE-PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatio ereby ,adehe S n Joaquin Local Health District for a permit to construct <br /> a install the to �d ribed. ' This application is made in compliance with San Joaquin <br /> ounty Ordin c the Rules and Regulations of t e San Joaquin Local Iteal.th District. <br /> ro <br /> OB ADDRESS/LOC a g z . - p -CENSUS TRACT <br /> er's Name Phone (J / <br /> Address �ViQ City f�'c�C r <br /> Contractor's Name License Phone jn <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN './_/ RECONDITION t / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR /—/ PUMP REPLACEMENT /-7 , <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPOF WELL CONSTRUCTION SPECIFICATI NS �1 <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea '¢ <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor ? <br /> Type of Pump H.P. ! <br /> PUMP REPLACEMENT: / / State work Hone <br /> PUMP 'tEPAIR: / / State Work Done - J <br /> ,DFCTRUCTION 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 Califoruia -pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of -my-work on a stew well,` I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the <br /> ­idand notify them before putting the well in use. The above <br /> informat' trketoC:e,,st of my knowledge and belief.SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIRE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY o , DATE <br /> ADDITIONAL COMMENTS: T - -- - - } f <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -L �1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING-AND FINAL INSPECTION. <br /> E x 1426 5/731M <br />