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n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOT'. SOF ICE USE:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -D S� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/,a <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 Sat, Joaquin <br /> T County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Vocal Health District. <br /> .TOB ADDRESS/LOCATION J yCENSUS TRACT <br /> Owner's Name ' Phone <br /> Address �j'� /j�, �� - City C3 <br /> Contractor's Name 1� � '�- License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP 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 n"61e Tool Dia. of Well Excavation _ Z <br /> ,---D-omestic/private. Drilled Dia. of Well Casing c) 1, <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal 'S <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r` <br /> PUMP. REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br />! DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> i 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 />'i SIGNED �_ �� _ _ TITLE <br /> s (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> a. PHASE I <br /> APPLICATION ACCEPTED BY DATE +� <br /> - ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> .-E-H.1426 5/731M <br />