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d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI..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 <br /> (Complete In Triplicate) 7y- <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 Sart Jbaquin <br /> County Ordinance No. 1862 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r U� CENSUS TRACT <br /> Owner's Name _.,i;J;��44Phone —_ <br /> Address City 40M = <br /> Contractor's_NameR n Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION './7 DESTRUCTION /_ <br /> PUMP INSTLATION f / PUMP REPAIR <br /> AL /��UMP REPLACEMENT. <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TA1NKSEWED EINES � PIT-PRIVY w - <br /> a SEWAGE DISPOSAL FIELD CE°SSP0OL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial Cable Tool Dia. of Well Excavation °Q <br /> Domestic/private Drilled j.;Bia. of Well Casing <br /> Domestic/public Driven ; Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other . t "+ Rotary Type of Grout <br /> r Z rOther Information <br /> PUMP INSTALLATION: Contractor ► <br /> Type' of Pump _ - - -- H.P. <br /> PUMP REPLACEMENT: / / i. State Work Done T- <br /> 4A_ d <br /> PUMP 'tEPAIR: / / State Work Done <br /> ! DFRTRUCTION OF WELL: Well Diameter r � ) 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 /> 3 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 /> ?i information tr to the st of my knowledge and belief. <br /> SIGNED TITLE rlf� <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BY �f DATE `7 <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL -FOR A GROUT INSPECTION.-PRIOR TO ,GROUTING AND-FINAL INSPEC N <br /> v 1 LII 5/731 <br />