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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OI'.:011ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> t 1�)b� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7 <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> i <br /> Address City <br /> Contractor's Name License #/74 Phon�-3,n /j <br /> TYPE OF 14ORK (Check) : NEW WELL DEEPEN /_/.' RECONDITION f_1 DESTRUCTION 17 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other -- <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 40 e <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 Done <br /> PUMP 'IEPAIR: / / State Work Done <br /> ,DFIQTRUCTION OF WELL: Well Diameter 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 /> 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 /> SIGNED '�� _ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> P-lik— <br /> APPLICATION ACCEPTED BY DATE ` ted W 1 y <br /> ADDITIONAL COMMENTS: b �. <br /> PHASE II GROUT INSPECTI N61� P E I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION INSPECTION BY DATE <br /> CALL FOR OUT INSPECTION PRIOR To GROUTING AND FINAL INSP ION. <br /> E H 1426 5/731M <br />