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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E F0F.,OFF1E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> El I - <br /> E THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> /( =t_Z (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 Sax Joaquin <br /> County Ordinance No.,.1862 sad the Rules and Regulations .of the San Joaquin Local }health District. <br /> JOB ADDRESS/LOCATION,,1W01. CSO-U/ CENSUS TRACT <br /> �-- <br /> Owner's Namey�� L Phone <br /> Address d J -:� /f✓ City ' r <br /> Contractor's Name_. License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PL'MI' REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES PIT PRIVY <br /> SAL F <br /> SEWAGE DISPOIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ► Cable Tool' Dia, of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing - <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other i I Rotary Type of Grout <br /> I Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> 1 <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 /> 14ELL DRILLERS REPORT of the iwell -and notify them 'before putting the well in use. The above <br /> i information is true to the Best of my knowledge and belief. <br /> t SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />�. FOR DEPARTMENT USE ONLY <br /> c PHASE I <br /> APPLICATION ACCEPT_ED YB *� `� t� DATE '� ti. <br /> ADDITIONAL COc�LMENTS: <br /> PHASE II GROUT INSPECTION. PHASE I /FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br />.� CALL FOR A GROUT INSPECTION•PRIOR TO GROUTING AND FINAL INS ION. ► T _ <br /> E H 1426 <br />