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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T-COt. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONIJ- ---. CENSUS TRACT <br /> Owner's Name Phone t <br /> Address - �� City��� <br /> Contractor's Name Gr .' License <br /> hone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /� RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC T&NK SEWER LINES,,a,2, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation .7 <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -� Gravel Pack Depth of Grout Se <br /> Other Rotary Type of Grout 9Y <br /> Other Other Information /► <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .� <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 tr a to the best of any knowledge and belief. <br /> SIGNEDPO TITIE <br /> DRAW PLOT PLAN ON REVERSE STV ) <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS- Y' TE 5 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION P TI INSPECTIO <br /> INSPECTION BY INSPECTI ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> H <br /> 14Z6 5/731M <br />