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�jSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.:OFFICE USE: `1.601 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 Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t10 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 aiid the Rules and Regulations of the San Joaquin Local Iteal.th District. <br /> a . <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner's Name Phone <br /> Address v City <br /> L ~ License.#j hone <br /> Contractor's Name d I-al <br /> TYPE OF WORK (Check) : NEW ,WELL y DEEPEN / I RECONDITION / / DESTRUCTION <br /> PUMA INSTALLATION f_1 PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f 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 `tEPAIR: State Work Done <br /> F <br /> r DF'-TRUCTION 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 DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> j 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 4 TITLE rywl - <br /> SIGNED <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> C PHASE I ` <br /> APPLICATION ACCEPTED .BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY ! DATE INSPECTION BY : DATE ' -t -17 <br /> 61 <br /> Ai�N� S r-� 6Rot'T <br /> FOR,A GROUT INSPECTION PRIOR <br /> GROUTING AND FINAL INSPECTION. <br /> CALL <br /> 5/731M . ;s' <br />