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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> AP ICATION FOR- WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> 4 � <br /> THIS PERMIT EXPIRES l 'YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tdIthe San Joaquin Local Health District for a permit to construct i <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 Regula ions of the San Joaquin Local. Health District. ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name f' Phone <br /> Address Qg k6 cz City OLWI <br /> Contractor's Name License �iPhone. - �� <br /> TYPE OF WORK (Check): NEW WEL'L _/R7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / { PUMP REPAIR / / PUMP REPLACEMENT <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 /> lilt <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing LIZ— 17 <br /> Irrigation Gravel Pack Depth of Grout Seal ° Z_ <br /> Other Rotary Type of Grout -e- <br /> i Other Other Information , 7 <br /> Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State WorIC"Done <br /> ESTRUCTION 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 <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 /> informa ion s true to the best of my knowledge and belief. <br />` SIGNED TITLE <br /> ! (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTEDf DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ►- <br /> CALL FOR A GROUT- INSPECTION PRIOR TO. GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />