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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fr-.On OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7� _ <br /> Telephone: (.209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> ;## (Complete In Triplicate) <br /> Application is hereby made toithe 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 J,baquinj <br /> County Ordinance No. 1562 andl the Rules and Y14uat ione £ �� San V� %{ :.r4, cal kte�l.th District. <br /> jot • CENSUS TRACT <br /> JOB ADDRESS/LOCA'TION ( v l C! <br /> }}' hone <br /> Owner's Name <br /> - � City <br /> .-f . <br /> Address �. <br /> Phone <br /> Contractor's Nave ►.. License 4}` <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION /i: TW 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> estic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing �. <br /> xrigation ravel Pack Depth of Grout Seal <br /> Other t Lary Type of Grout <br /> �jOther Other Information . <br /> ------------------- <br /> }PUNP`INSTALLATION: 'Contra ctor ��,•-s H.P. <br /> Type-'of P m - --- . <br /> 4- <br /> PIMP REPLACEMENT: N i/ / State Wark Donel t <br /> 'PUMP 'tEPAIR: I I -} • . <br /> , State Woxk Donee '`` '• <br /> DFgTRUCTION_OF WELL: We114DiAmeter pP oximate 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 /> the State of California pertaining to or regulating well'cons_truction. 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 thembefore putting the well in use. The above <br /> l "-,inform 'on is true to the 'best o knowledge -and-belief_. - " <br /> SIGNED TITLE <br /> SIGNED —_ <br /> W PLOT PTAN ON REVERSE SIDE) <br /> a F R DEP TMENT USE ONLY <br /> s <br /> a PHASE �IfAd EL _ DATES <br /> j, APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS <br /> + F S GROU ' INSPECTION P II/F NAL INSPECTION <br /> INSPECTION BY DATE — 0 INSPECTION B _i DATE <br /> CALL FOR A GROUT IN5PEGT ON .PRIElR-.TO GROUTING AND FINAL INSPECTION. . <br />