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{ <br /> �R. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL:OFFICE US.E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7_L.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued '�` <br /> - (Complet&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 J0aquin4 <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ���'% CENSUS TRACT <br /> Owner's;Name Phone <br /> Address U T Cit r <br /> _ y <br /> Contractor's Name License 16?WFaf Phone <br /> TYPE OF WORK (Check): NEW WELL ,�/ DEEPEN ,/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PIMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK (,60 SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS <br /> Industrial Cable. Tool Dia. of Well Excavation f ,� <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing /0 94 { <br /> Irrigation Gravel Pack Depth of Grout Seal [� <br /> Other Ro Type ofGrout <br /> Other; Other Information <br /> PUMP INSTALLATION: Contractor <br /> :1 <br /> Type of Pump H.P. 5 <br /> _ <br /> PUMP REPLACEMENT: / 7 State Work Done <br /> _ l <br /> PUMP 'zEPAIR; / / State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> an-d--the--State_o:f_Californi.a pertaining. _te.or Yregul.ating_.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 u:se. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED Of _ _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)PHASE I t/ - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY7r DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DTE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E.H 1426 P 5/731M <br />