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__ .4 JOAQUIN LOCAL HEALTH DISTRIC <br /> ,Jt. Ol'1''1C1; USL ; 1601_'E. <br /> E. Hazelton Ave. , Stockton, Cafrf,, <br /> _. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.z� - S`J(o&j <br /> t_ • - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/,z_ 3-7q <br /> (Complete In Triplicate) <br /> -Application is hereby made to the San Joaquin Local Health District for a permit to cors: , u�_t <br /> and/or install the work hereinescribed. - This application-i mad ,p ompliance with San Joaquiz <br /> County Ordinance No. 862 n u esd/ 8 �a c} ,uin Local. ilea] th District. <br /> JOB ADDRESS/LOCATION GC.. SUS TRACT <br /> Owner's Name Phon <br /> ZAL <br /> Address City <br /> Contractor's Name cense hone <br /> _TYPE OF WORK (Check) : NEW WELL f / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> U,11P INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> ;E <br /> Other <br /> -DISTANCE TO NEAREST: SLPTIC TA1':i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICI�TIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled Dia, of Well Casing l <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 /> PUP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> y PUMP `ZEPAIR: / / State Work Done <br /> DFG TRUCTION 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 /> :,{ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we and notify them before putting the well in use. The above <br /> information s true to the b t f my knowledge and belief. <br /> SIGNED TITLE <br /> {DRA PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> ��As x_ <br /> APeLICATION ACC'E'PTED BY DATE <br /> ADDITIONAL COMENTS <br /> P3ir_5E II ROUT INSPECa'I PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 <br /> - CALL IUGR A GROUT INSPECTION PIZIf3i.\, TO GROUTING AND FINAL INSPECTION. <br />