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J� <br /> .SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5r_ -digaCE 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 1 YEAR FROM DATE_ ISSUED Date Issued oZ - <br /> (Complete In Triplicate) <br /> Application is hereby .,pade 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 Regulation of the San Joaquin Racal Health District. <br /> �� / Apz� <br /> JOB ADDRE�7/LOCATION ,� f.Z 0 =-- ENSUS TRACT <br /> Owner's Name � � 5 Phone � <br /> Address 4 G a City/�es � s�a <br /> Contractor's Name License Phone k <br /> TYPE OF WORK;„(-Check) : NEW WELL / DEEPEN / j RECONDITION /_/ DESTRUCTION /? <br /> } PUMP INSSTTMATION / f PUMP REPAIR / / PUMP REPLACE T /-7 <br /> Other / / :ZS <br /> (DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n <br /> X INTENDED USE TYPE OF WELL X CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <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 /> P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> PUMP. 'tEPAIR: _ / J ,State_. Work Done <br /> .DF�TRUCTION OF WELL: Well Dila eter 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 /> j 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 />' F PARTMENT USE ONLY <br /> w PHASE I <br /> APPLICATION ACCEP DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I INAL INSPECTI4 <br /> INSPECTION BY DATE INSPECT] ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - - - 5/731M <br />