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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />'i Telephone: (209) 466-6781 <br />!k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 z&7 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED G. Date Issued -17- 6 <br /> x� (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 inlicompliance with San Joaquin <br /> County Ordinance Na. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> �j <br /> :i Phone ' <br /> Owner's Name <br /> ' Address 'Z j City ' ' <br /> Contractor's name ( iL:� License I =I?hon <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION 17 <br /> PUMP INST LATION �/ PUMP REPAIR '/ / PUMP RE"LACEMENT /_T <br /> Other <br /> + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRTVY1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )( Domestic/private _ _ Y Drilled Dia. . of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other Other Information <br /> s PUMP INSTALLATION: Contractor <br /> Type of Pump k H.P. <br /> 4 'UMP REPLACEMENT: / /� State Work Done <br /> i PUMP `tEPAIR: / / State Work Done <br /> DFCTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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. I� A <br /> i <br /> j SIGNED TITLE �I <br /> (DRAW PLOT PLAN ON REVERSE SIDE):I <br /> FOR DEPARTMENT USE ONLY �J / <br /> PHASE I � � �� ` y <br /> I APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE /FIN INSPECTION <br /> ' INSPECTION BY DATE ��. / 7� _ INSPECTION BY DATE :57 <br /> CALL FOR A GROUT INSPEC ION PRIOR TO GROUTING.AND FINAL .INSPECTION. <br /> 5/731M <br />