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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r7o .:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I1 <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> i (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. 116al.th District. <br /> JOB ADDRESS/LOCATION 1 /i CENSUS TRACT _ <br /> Owner's Name Phone <br /> Address A- <br /> City <br /> Contractor s Name: - License Phone <br /> TYPE OF WORK (Check) : NEW WELL�./�DEEPEN �/ -RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / !PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other m/ <br /> DISTANCE TO NEAREST: SEPT!C"TANK_. -_. SEWER LINES PIT PRiVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : n <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 ; M -V/&" CIU2 <br /> �V Irrigation Gravel Pack Depth of Grout Seal <br /> Other - <br />� �/ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Typelof Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Dane <br /> - - - ,,,.; -: z= •.ter-.� .« ,.;_ -�� _ <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFRTRUCTION 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 worn 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 /> informati n is true to t e best of my kndkledge and belief. <br /> SIGNED TITLE <br /> (DRKW P AT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEP EB�I�a y E -� - <br /> ADDITIONAL CO' S _ <br /> SE GROUT INSPECT N P I NAL INSPECTION <br /> INSPECTIONB DATE - 7- INSPECT / � " DATE <br /> C 4 <br /> - CALL FOR A-GROUT-INSPECTION-PRIOR TO GROUTING-AND FINAL INSPECTION. <br /> E. H 1426 K/711 m <br />