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_ SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FOF. 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 /> 4F <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 J,baquin ! <br /> County Ordinance Noi -1862 .and the Rules- and Regulations .of the San Joaquin Local Health District, i <br /> JOB ADDRESSJLOCATION. CENSUS TRACT <br /> r <br /> Owner's Name Phone <br /> Address City ' . <br /> Contractor's Naze License #.'- T hone '4/46_706 s <br /> ' 1 <br /> TYPE OF WORK' (Check) : NEW WELL/ DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /)I� PLW REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST:' SEPTIC TANK~~ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i pp ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS �V <br /> Industirial ' Cable Tool , Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing "Q <br /> Domestic/public - FDriven Gauge of Casing 0 <br /> Irrigation Gravel Pack ---Depth of Grout Seal ' <br /> Other Rotary -Type of Grout <br /> Other Other Information' <br /> ' a <br /> PUMP INSTALLATION: Contractor _. <br /> Type of Pump H.p. ' i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: /%. State Work Done <br /> .DFc,TRUCTION 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 orregulating .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 /> IC-LL DRILLERS REPORT of the well and notify thew before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE ' <br /> (DRAW .PLOT PLAN ON REVERSE IDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -BY�� -k/ DATE �.r <br /> ADDITIONAL <br /> COMMENTS: )4 -d � `– <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -2 c/ INSPECTION BY DATE, . <br /> 1 <br /> CALL k'OR A-GROUT INSPECTION PRIOR TO GROUTINGaAND-FINAL INSPECTION, <br /> E H U91r, I I r /ten___ <br />