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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I L,Oi�1�ICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z- 1372 $'w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 aAd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI N 02 YfCENSUS TRACT �( <br /> Owner's Name Phone <br /> 1 t <br /> r <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN/J RECONDITION/_/ DESTRUCTION <br /> PUMP- INSTALLATION / / Pl�'MMP REPAIR / / PUMP LACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE =PE 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Other 'r Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f PUMP REPLACEMENT: J / ,, State Work Done <br /> PUMP ''tUPAIR: /t;f. State Work Done <br /> _DFGTRUCTION OF WELL: Well Diameter �j Approximate Depth jwir <br /> Describe Material and Procedure rdf <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 /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PEASE I f �/ <br /> F APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMHCNTS: <br /> PHASE II GROUT INSPECTION PHASE III/ ANAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B _DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 K/711 wr <br />