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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1I0£. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S 3� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedc - -�3 <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 /> JOB ADDRESS/LOCATION A/I! CENSUS TRACT <br /> Owner's Name rI'J d /J Phone <br /> Address �.� y City _ se 1a�KQ-o <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION J PUMP REPAIR /-/-PUMP REPLACEMENT /- <br /> Other /-7 <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 <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 .5ml ,rJ <br /> Type Of Pump H.P. ' <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFCTRUCTION 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 /> 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 /> ' <br /> SIGNED <br /> � TITLE <br /> (D LOT PLAN ON REVERSE SIDE) <br /> ` F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHAW.p jA d%2LJ7IN0EGTMI INAL INSPECTLQW <br /> INSPECTION BY DATE INSPAQ J&& DATE -. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1.426 -- -- 5/.731M <br />