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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E OFFT.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 S- /3f' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT. 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 /> .TOB ADDRESS/LOCATION � �'— <br /> CENSUS TRACT <br /> Owner's :[dame <br /> Phone '76-7` 3--: r <br /> j <br /> Address City" <br /> Contractor's Name c5 S 3 License ���g3�� Phone <br /> TYPE OF WORK (Check) : NEW WELL /'�;r DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /`7` <br /> PUMP INSTALLATION /O'PLW REPAIR / I PUMP REPLACEMENT /_T <br /> Other / / <br /> DISTANCE: TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Domestic/private 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 r <br /> Other Other Information •Ef- <br /> PUMP INSTALLATION: Contractor ie S <br /> Type of Pump H.P. %D <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> _ � q <br /> DF9TRucTioy OF WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i 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 /> f <br /> i - <br /> SIGNED( TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> i PHASE I. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE II/FI INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE s ?A 7r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - - 5�731M <br />