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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O 61 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. s`',�� <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION CENSUS TRACT , . <br /> t r p <br /> Owner's NamePhone �J �aQ <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /? <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 Cable Tool Dia. of Well Excavation (Jj . <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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work DoneALAI <br /> PUMP REPAIR: / / 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 Satn 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-urell;; I will furnish-the San Joaquin Local Health District a <br /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information 's true to the 'best"of my-knowledge and belief <br /> a <br /> SIGNED TITLE1")-YL+2� i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` // <br /> APPLICATION.ACCEPTED .BY DATE !I t+ <br /> ADDITIONAL COMMENTS: f 7 � / <br /> PHASE Ii RROUT INSPECTION PHASE II INAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY 17-5 <br /> DATE / ,� <br /> , CALL FOR A GROUT 'INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> Tr I / If' c�I'7' 1•Alr <br />