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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7,,0r.�OFF10E 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 /> '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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> 2�6 2 . <br /> JOB ADDRESS/LOCATIONENSUS TRACT <br /> i <br /> Owner's Name U'LL Phone <br /> Address „?/„ Cityg� i <br /> Contractor's Name r License # Phone <br /> . .�� - <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN './—/ RECONDITION [—/ DESTRUCTION /- s <br /> PUMP INSTALLATION / / PUMP REPAIR'/—/—PUMP REPLACEMENT /-7 <br /> Other;,/—/ — ---- <br /> i <br /> DISTANCE TO NEAREST: "SEPTIC .TANK y6LrSEWER LINES PIT PRIVY <br /> SEWAGE'IbISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation /O � <br /> _ Domestic/private Drilled Dia. of Well Casing �� _ s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,.DC7' , <br /> Other Rotary Type of Grout ,� Z=IZZ2 � <br /> ' Other Other Information '.,-�/� 15 -Ae, a2aaz <br /> PUMP INSTALLATION: Contractor <br /> Type o.f Pump H.P. <br /> PUMP REPLACEMENT: }� <br /> / I State Work Done ; <br /> - <br /> PUMP UPAIR: y / / State Work Done <br /> .DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure • <br /> .i <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''constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WkLL 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 /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P1kSE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I F <br /> PRASE II GROUT INSPECTION P,,RAA III NSPECTION <br />,. INSPECTION BY DATE INS <br /> CA:LI; FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E ,H 1426 /731M <br />