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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Q-2 7-7_S— F <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. 1862 and the Rules and egulations of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIPki zd'_ e CENSUS TRACT 1L <br /> Owner's 'Name i Phone ' <br /> Address 0o City �� <br /> tl <br /> Contractor's Name - .,c. ..� - License # Phone e <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ _DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP'REPLACEMEI3T /� <br /> i <br /> Other /_7 <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TA.ti7K SEWER TINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> � i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information l <br /> PUMP INSTALLATION: Contractor <br /> I <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <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 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 t the best of my knowledge and belief. <br /> SiGNED --Z. TITLE - -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COZ0IENTS; <br /> PHASE II GROUT INSPECTION - PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE - - V. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />