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i <br /> JOAQUIN LOCAL HEALTH DISTRI( <br /> tat7i 'pF; SCS USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> `f .Telephone: (.209) 466-6781 <br /> j � APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUER Date Issued/'/C 10V <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. 1 62 and the Rules a d Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S OEs, CENSUS TRACT <br /> Owner,'s Name ,�"` ,E <br /> :Phone 6 `- <br /> Address c� City <br /> ;I <br /> Contractor's Name License # Phone <br /> TYPE ,OF WORK. (Check) : NEW WELL /% DEEPEN / RECONDITION / / DESTRUCTION /_7 ' <br /> PUMP INSTALLATION <br /> PUMP I / PUMP REPLACEMENT /-7 <br /> Other / / — <br /> r <br /> i!DISTANCE TO NEAREST: SEPTIC TIUNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j <br /> INTENDED USE TYPE OF WELLCONSTRUCT ION SPECIFICATIONS <br /> i° Industrial Cable Tool Dia.. of Well Excavation ! j <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 /> :PUr1P INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: 47 State Work Done <br /> : PUMP ZEPAIR: / / State Work•Done <br /> ,iDFGTRUCTION OF; WELL: Weil -Diameter Approximate Depth <br /> Describe'. and Procedure <br /> 1 -- - -- <br /> I hereby agree to comply with alll ,�aurs and regulations of the San Joaquin Local Health District <br /> : and 'the State o.f` California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 'rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1WELL'' DRILLERS REPORT o€ -the well and notify them before putting the well in use. The above <br /> ;i information is true to ,the best of my knowledge and belief.' <br /> !jSIGNED TITLE`` r. 1/2 _ -- - — <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE i <br /> €� APPLICATION ACCEPTED BY DATE <br /> f ADDITIONAL COlvDtiNTS: <br /> PRASE II GROUT INSPECTION %Pffi&E II/FINAL INSPECTIONINSPECTION BY DATE INSPECTION BDATE "1 �� <br /> fi CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL .INSPECTION. <br />