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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> r7o .A:OFFICE USE: !l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 2- <br /> 7-(Complete <br /> .(Complete In Triplicate) <br /> Application is hereby made to.1the 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 Joaq,ui.n <br /> County Ordinance No. , 1862:.and the -Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION � . CENSUS TRACT <br /> Owner's Name Phone ? f6 76 <br /> ` <br /> City .t. ,. <br /> Address <br /> Contractor's Name. Y License # Phone <br /> TYPE OF WORK (Check) :. NEW WELL J_7 DEEPEN ' RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other .-,/ <br /> --- <br /> ;;a: <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE"bISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation 7. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing c, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other t Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP `REPAIR: /% State Work Done <br /> ,DFCTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above r <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) tl <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .� DATE <br /> ADDITIONAL COMMENTS: <br /> ;t .. PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL-FOR A­GROUT -INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/737 <br />