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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICL USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I,. YEAR FROM BATE 'ISSUED Date Issued � <br /> (Complete In Triplicate) <br /> Application is hereby ;Wade 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 w:lth San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 14alth District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> - I <br /> Owner's Namea <br /> Phone <br /> Address . L 9 1:2:2 � _ City S C'221 ,.t) <br /> Contractor's Name / License #01'2790)rjPhone r <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT— <br /> Other ./ <br /> EPLACEMENTOthen /% `— ---- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> I <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: )1:;K State Work Done �,,a , .z ✓ �� [i/. <br /> PUMP T2EPAIR: / / State Work Done <br /> ,DFOITRUCTION 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"HAYS � <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 these 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 <br /> APPLICATION ACCEPTED BY /' DATE I3 <br /> ADDITIONAL COUNTS: . <br /> PHASE II G OUT INSPECTION PgA. IZOVNAL INSPEC' jO <br /> INSPECTION BYDATE INSPEON DATE <br /> CALL FOR A GROUT INSPECTION- PRIOR TO GROUTING AND FINAL INSPECTION. � <br />