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N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£ OFFICE„TSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �u Telephone: (209) 466-6781- <br /> 2 ;;&APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No.7-- <br /> -3 i <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 constr.u.ct <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 /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> f <br /> Ovr er':'s Name Phone <br /> r <br /> Address City <br /> Contractor's Name <br /> Licensei` Phone <br /> t <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /? RECONDITION /_{ DESTRUCTION /-7' PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT I-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V111 <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> VrZDomes Drilled, Dia: of Well. Casing �G <br /> I <br /> Domestic/public Driven Gauge of Casing <br /> Irri ation -� Gravel Pack Depth of Grout Seal <br /> Other y Rotary Type` of Grout <br /> Other Othef`r Information ' . <br /> PUMP INSTALLATION: Contractor H>P. <br /> Type of Pum <br /> PUMP REPLACEMENT: State Work Done <br /> i PUMP `tEPAIR: State Work Done <br /> iE <br /> PF-,TRUCTION OF .WELLc " Well Diameter Approximate;°Depth <br />' :: Describe Material and Procedure j <br /> I hereby agree to •comply with all Laws andFregulatons. of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'constru:ction.' 'Within .F.1, DAYS <br /> after completion of my work on a neta well, I will furnish the San Joaquin Local =Health District a <br /> 14ELL DRILLERS REPORT of .the well aid notify thew before putting the well in fuse. The above <br /> informat1on is true ;=17= <br />'i SIGNED TITL <br /> (DRAW OT PLAN ON REVERSE DE) <br /> OR DEPARTMENT USE ONIff <br /> PHASE Ir <br /> APPLICATION ACCEPTED .B �J • DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT O rY' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />�' F H 1426 5/731M <br />