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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O£. O11 ICE USI:• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issue d�`. <br /> (Complete In Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> work herein described. ' This application is made in comp7.iance with <br /> hhSan Jrict.n j <br /> and/or install the � � <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local �leg1t <br /> . CENSUS TRACT <br /> JOB ADDRESS/LOCATION ! _ <br /> -� Phone <br /> Owner's Name <br /> City <br /> AddressOm r <br /> l �' e <br /> �/,o�, License Phone � � T" <br /> Contractor's Name <br /> STRUCTION 1.7 <br /> TYPE OF WORK (Check) : NEW WELL mDEEPEE /_�/; ,�tECONDITION !PUMiD'EREPLACEMEN' 1_7 <br /> PUMP INSTLAlION/ j PUMP REPAIR f <br />[ Other <br /> DISTANCE TO NEAREST: SEPTIC T)U4K SEWER LINES PIT PRIVY OTHER <br /> 3L3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ; <br /> k ' <br /> INTENDED USE OF WELL CONSTRUCTION +.SPECIFICATIONS <br /> Industrial '`Cable Tool Dia. of Well. Excavation <br /> Drilled Dia. of Well Casing <br />{ <br /> Domestic/private Gaul <br /> a of Casing <br /> Domestic/public �Driven 8 <br /> Irrigation '' ' Gravel Pack Depth of Grout Seal f <br /> Rotar Type of Grout <br /> - �Othery <br /> Other � Other Informations. <br /> f <br /> f PUMP INSTALLATION: Contractor <br /> Type .of Pump`., <br /> PUMP REPLACEMENT: / / State W6rk Done <br /> AV, <br /> PUMP <br /> REPAIR: j / State work Done <br /> Approximate Depth <br /> DF9TRUCTION OF WELL: Well Diameter � . <br /> k 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 Stare 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 DR IL PORT of the well and noti'fy)fhern ,before putting the well in use. The above <br /> # informati. is t e to b t of m <br /> y knowledge and belief. <br /> r TITLE <br /> SIGNED ,� <br /> -- - (DRAW-PLOT PLAN• ON-REVERS <br /> SIDE;. <br /> FOR DEPARTMENT USE ONLY. w <br /> i PHASE I - _ DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS I NAL I PE O <br /> PRASE II GROUT INSPECTION INSPECTION BY TE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5 0 3 1M <br />