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l� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL;OF'FICE USF:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS <br /> PERMIT EXPIRES 1-YEAR:FROM DATE ISSUED Date Issued �� <br /> # (Complete In Triplicate) <br /> Application is hereby madelto the San Joaquin Local Heaith .District for a permit to construct <br /> and/or instal]Athe work herein described. This application is made in compliance with San Joaquin <br /> County Ordinante .No, 1862 Ad the Rules and Regulations ofthe San Joaquin Local He' .t.h District. <br /> .JOB ADDRESS/LOCATION LLI. t CENSUS TRACT <br /> Owner's Name Phone <br /> i / t ��+� �- <br /> Address �X� City <br /> Contractor's Name 1y License ,t7 Phon�` 13 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PLW .REPAIR / PUMP REPLACEMENT / <br /> ` Othr <br /> DISTANCE TO NEAREST: SEPTICTA-,K SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE t .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 N <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 Bone <br /> � t <br /> PUMP -State Work Done` <br /> ,DFRTRUCTION 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 wolik on a new well, I will .furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of tine 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 /> { <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE `- <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: <br /> PHASZ II GROUT INSPECTION P E III FINAL INSPECTION <br /> INSPECTION BY DATE T -- INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND "FINAL INSPECTION. <br /> 5/73lst <br />