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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.; Stockton, Cali€. <br /> TeYephone: (209) =465-67$1 <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 horeby-made. tb theeSan. Joaquin. Local Health :District. for a .permit to construct <br /> and/or install the work herein described. This application is made-incompliance with San Joaquin <br /> County,Ordinance No. ;1862 -and:,,.the4Rule ''and R ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION =. CENSUS TRACT ' <br /> Phone <br /> Owners Name <br /> �. <br /> City <br /> Address c-?CJ - -- <br /> Contractor s 'Name <br /> License # Phone <br /> as732 <br /> f TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP =INSTAL TIO /� PUMP PAIR / I PUMP REPLA EMENT- /7 <br /> f Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C+i► <br /> ! Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i-1 : State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Welf 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 true to the best of my knowledge and 'belief. <br /> SIGNED ��'� <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT �INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYi�ae DATE -� 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 <br /> EH 1426 T <br />