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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF. 03.7 MIS E �' 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 I YEAR FROM DATE ISSUED Date <br /> :, - . (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... 1862 and the Rules and Regulations of the San Joaquin Local Health District. a <br /> JOB ADDRESS./LOCATION r r CENSUS TRACT <br /> Owner's Nance Phone <br /> Address City ,t <br /> 1 �C= <br /> Contractor's Name �� � - x7c^ License l hone <br /> TYPE OF WORK (Check): NEW. WELL / / DEEPENX RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT JK/�j*Q *_ <br /> Other <br /> . ^6z <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 lg <br /> Domestic/public Driven Gauge of Casing ° <br /> Irrigation Gravel Pack Depth_ of Grout Seal ., <br /> Other Rotary Type of Grout <br /> t <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type ;of Pump <br /> i E <br /> PUMP REPLACEMENT: / / State Workl Done <br /> PUMP `tEPAIR: <br /> States_Wvrk Dane ; <br /> . E <br /> ..DFgTRUCT'ION OF WELL: Well Diameter _ Approximate Depth <br /> Describe MatIrial 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,.nex4, well, I will -furnish the San Joaquin Local Health District a .t <br /> CvELL DRILLERS REPORT Che well and• notify them before putting the well in use. The above E, <br /> information is tr t know ge and belief. <br /> SIGNED / _�, -G� � TITLEd4- <br /> (DRAW PLOT PLAN ON REVERSE SID ' <br /> 1 <br /> FOR DEPARTMENT USE ONLY CZ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> - <br /> ADDITIONAL COMMENTS: ° <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL-FOR .A.GROUT.•INSPECrION-PRIOR:TO GROUTING AND .FINAL. INSPECTION.- <br /> 7 u ,A1)r_ ff /.71.1. ( <br />