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SAN JOAQUIN• LOCAL H <br /> FOR EALTH DISTRICT T A T <br /> R OIFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> Date Issued (. <br /> San Joaquin Local Health District far a <br /> (Complete In Triplicate) <br /> Application is hereby made to the S <br /> and/or install the work herein described. permit to construct <br /> This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> JOB ADDRESS/LOCATIONee District. <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address � �� <br /> �'� 'G CitySC/a1,. �.f <br /> Contractor's Name <br /> License # Phone 0t1'v_33c7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / J �PU,�1P REPAIR PUMP REPLACEMENT /_7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT <br /> OTHER � <br /> INTENDED USE TYPE OF WELL v <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Drilledd <br /> Cable Dia, of Well Excavation ' <br /> Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal q <br /> Other ! <br /> Rotary Type of Grout ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump — �} <br /> _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done (� <br /> PUMP REPAIR: /4T$- State Work Done ,� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIIIE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 4/ <br /> ADDITIONAL COMMENTS: DATE tJ <br /> PHASE II GROUT INSPECTION P III/ IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4172 1M <br />