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SAN JOAQUIN4LOCAL HEALTH DISTRICT <br /> FOi_:OFF'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <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 r.-Lad-e to the San Joaquin Local Health District for a permit to construct <br /> and/ox 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 Health District. 3 <br /> JOB ADDRESS/LOCATION �Gi ,Q. CENSUS TRACT <br /> Owner's Name jy(�� Phone <br /> Address / ,o City ,gyp • <br /> Contractor's Name License ��f� Phone -33y ` <br /> TYPE OF WORK (Check) : NEW WELL '/I;f-- DEEPEN '/ / RECONDITION /_{ DESTRUCTION 17 ; <br /> PUMP INSTALLATION _X�_ PLW REPAIR / PUMP REPLACEMENT /7 <br /> Other ./ <br /> V} <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 /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 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: 2EPAIR: / / State Work Done <br /> , F9TRUCTION OF WELL: Well Diameter Approximate Depth C <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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I 4 s <br /> APPLICATION ACCEPTED .BY DATE '?,.E� <br /> ADDITIONAL CO;OMENTS; <br /> PHASE lI'GROUT INSPECTI N PHASE JIIJFINAL INSPECTION <br /> INSPECTION BY., DATE. INSPECTION BY .DATE /2-5= � <br /> -CALL FOR•A-GROUT.-INSPECTION PR10R TO GROUTING AND FINAL INSPECTION. e <br /> r- it , r_nr - - Ef /7`l�v - <br />