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SAN JOAQUIN LOCAL HEALTH DISTRICT .� <br /> FOS'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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. <br /> ]� i.l il�,.. 94- ak_:5262/ CENSUS TRACT <br /> JOB ADDRESS/LOCATION :�::�,�a <br /> Owner's Name r Phone - 5a <br />_ Address -k- City <br /> i <br /> Contractor's Name r0.5 / License # ZZ& Phone - <br /> TYPE OF WORK (Check) : NEW WELL //rf DEEPEN '/ I RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION j_/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other l I <br /> DISTANCE TO NEAREST: SEPTIC TiiN_K 7L SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /342 t CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. - Cable Tool Dia. of Well Excavation _ /Q f' <br /> Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing .2 C!; <br /> Irrigation Gravel Pack Depth of Grout Seal ta _ <br /> Other ��/ Rotary Type of Grout <br /> Other Other Information s �+ <br /> PU'.1Q INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP:REPLACEMENT: _ / /-. __State tWork done_ �. <br /> PUMP '�.EPAIR: / / State Work Done <br /> ;DF'CTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Materia. 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:'constiuction. Within FIFTEEN DAYS <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 them before putting the..well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> f <br /> SIGNED TITLE <br /> (D OT PLAN ON REVERSE ASIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE «r <br /> ADDITIONAL COMMENTS: Z571 1K,Y <br /> P SE 1I GROUT INSPECTION Plwse I INAL INSPECTION <br /> INSPECTION B DATE - INSPE DATE <br /> - CALL'FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. (,/7 q7M �� <br />