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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.:OFFICH USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _A�-n- <br /> (Complete In Triplicate) <br /> Application is hereby Zdeto the San Joaquin Local Health District for a permit to construct <br /> axed/or install the work herein described.,. .is application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules. And gula ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,�j CENSUS TRACT G G 6 <br /> Owner's Name <br /> t <br /> Address - City . <br /> Contractor's Name7� License Phon(9 <br /> TYPE OF WORK (Check) : NEW WELL RIT DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR j j PUMP REPLACEMENT /7 q <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS L FIELD CE POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ( . Cable Tool Dia. of Well Excavation 1� + <br /> T Domestic/privateDrilled Dia. of Well Casing 4\ <br /> Domestic/public t Driven Gauge of Casing f <br /> Irrigation t Gravel Pack Depth of Grout. Seal. <br /> Other �'Rotary Type of Grout <br /> t Other Other Information t <br /> •t t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - - - - H.P. <br /> PUMP REPLACEMENT: j j State Work Done <br /> PUMP 'ZEPAIR: / / State Work Dome <br /> ,DI'CTRUCTION 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 I <br /> after completion of my work an a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the %tell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNER <br /> TITLE <br /> -- -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,�t / FOR DEPARTMENT USE ONLY <br /> PHASE X IL.V <br /> APPLICATION ACCEPTED BY DATE_ <br /> ADDITIONAL CO►Z124ENTS: <br /> P I OUT INSPECT IO IPHAE I I/FINAL INSPECTI INSPECTION B , DATE L INSPECTION .BDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTINGa ..AND FINAL INSTION. u <br /> 011'142 6 Jas' 5/7 <br />