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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£. OFFICE USE: SAN <br /> L Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 � <br /> 1 (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 Joaqu <br /> County Ordinance No. 1862 acid the Rules and Regulations of the San Joaquin Local Health District <br /> 7 t <br /> JOB ADDRESS/LOC ON CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> 7C/i�ty�,. 1 / <br /> Contractor's Name J License 4� hon 6,C3 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_% RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST ILLATION / / PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TA2N-K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation t <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 l' 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 'tEPAIR: / / State Work Done <br /> t <br /> DR.-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> // <br /> APPLICATION ACCEPTED .BY lit/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY - INSPECTION BY DATE 3-3- 7 d <br /> .�.CALL-FOR-A-GROUT-INSPEC ON PRIOR TO .GROUTING AND FINAL INSPECTION. <br /> E R IL9A N. <br />