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Lk <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF. 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 l 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 /> , Lid/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 /> ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Q�ner's Name iAa � .rF"Y\ Phone <br /> �i a <br /> Address Q a. � City ' <br /> contractor's Name - License 4T�,Zzg' Phonegg, - bl3 <br /> I� <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <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 V <br /> Domestic/private �'I Drilled Dia. of Well Caging <br /> 11 Domestic/public Driven Gauge of Casing <br /> !t. Irrigation _ Gravel Pack Depth of Grout Seal <br /> IM. Other Rotary Type of Grout <br /> IM Other Other Information . <br /> I� <br /> PJMP .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done , <br /> DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E 1 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 to the best of my knowledge and belief. <br /> ISIGNEDLp /� - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I /FINAL INSPECTION <br /> INSPECTION BY Ta%jw%. "'�NSPECTION BY DATE <br /> I <br /> CALL FOR A GROUT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ .5/731M <br />