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l/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F{}F,illrziu USE: 1601 E. Hazel.ton:Ave. , Stockton, Calif. <br /> f � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7L_ <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z_:., <br /> (Complete In Triplicate) <br /> Application is hereby wade 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I S� CENSUS TRACT ' <br /> Owner's Name ■ > Phone <br /> Address . City <br /> i { <br /> Contractors Name ` d" - _ License Phone <br /> TYPES OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION 1- <br /> PUMP INSTALLATION PUMP REPAIR "/ I PUMP REPLACEMENT /_7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TA,,!—K-- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> SPECIFICATIONS <br /> CONSTRUCTION SPEC <br /> INTENDED USE TYPE OF WELL `C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Af <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout d' <br /> Other Other Info at'on <br /> if.r, <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> I <br /> i .PFATRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 77 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> q and -the State of California pertaining to or regulating we1l''construction. Within FIFTEEN DAYS <br /> Y <br /> � after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL LLERS REPORT of the well and notify them before putting the well, in use. The above <br /> y <br /> jinf rmati is t t the best of my knowledge and belief. <br /> GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)4" <br /> FOR DEPARTMENT USE ONLY <br /> p PHASE I <br /> i APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COM4ENTS: <br /> PHASE I G OUT INSPECTION PHASE III/FcT AL INSPECTION <br /> INSPECTION BY DATE _ <br /> INSPECTION BY RATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> IT 1d9� : 71/`4 <br />