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D / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ..OFFICE �11601 USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permif o,,'2 <br /> !I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> i <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. <br /> "cThis application is :Wade in compliance with San Joaquin <br /> County Ord name a 62 and the Rules and Regulations of the San oa uin Local Health District. <br /> JOB g�ILOCATION 0/i_T r S TRACT - <br /> owner's Name <br /> �M Phone <br /> Address <br /> � city <br /> Contractor's Mame <br /> License # , ,,Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN <br /> RECONDITION /_7 DESTRUCTION /'T <br /> F PUMP INSTALLATION / ' PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER i.INES <br /> SEWAGE DISPOSAL FIELD �-�- C PIT PRIVY � .�! <br /> t60L/SEEPAGE PIT0 &THER <br /> INTENDED (USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <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 /> Other �� G? <br /> Rotary Type of Grout C-C. <br /> Other E�g <br /> Other Information <br /> PUMP INSTALLATION: ' Contractor <br /> Contractor <br /> Type of Pump <br /> ----- <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> i <br /> .RESTRUCTION OF WELL. Well Diameter ' <br /> 1 Describe Material and Procedure Approximate Depth <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 G4 ue to the -best of my knowledge and belief. <br /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE). <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTI N PHAS�INA PECTION <br /> INSPECTION BY f DATE - INSPECTION BYE <br /> c� <br /> CALL FOR A GROUT INSPECTION PRIORTOGROUTING AND FINAL INSPECTION. <br /> E H 1426 1 /121M i <br />