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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. Ok'FICE ,USE:-, 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ` p <br /> THISPERMIT 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. Sant Joaquin <br /> County Ordinance No. 1862 and tete Rules and Regulations of the San Joaquin Local. 1i.t.lth District. <br /> .TOB ADDRESS/LOCATION1 CENSUS TRACT <br /> Owner's Name L.r ke-, C phone <br /> Address City. <br /> f Contractor's Name License 1�,� Phon <br /> TYPE OF WORK (Check) : NEW WELL 4' DEEPEN / / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERAj <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Jl <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: / J State Work Done <br /> PUMP `tEPAIR. / / State Work Done , <br /> .DFSTRUCTION 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 there before putting the well in use. Th above <br /> information, is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PIAT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P S IT GRO INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _! - fr��+r� <br /> CALL FOR A,- OUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />