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SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> FOR OFFICE USE: b 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUYIP. PERMIT Permit No. W `ZAP <br /> 'h,,1 - <br /> THIS*PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,3-2-1 <br /> (Complete In Triplicate) a r <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 applicati6n- 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 CENSUS TRACT -_ <br /> Owner's Name Phone <br /> Address I.LQV # qCity <br /> Contractor's Name License # Phone <br /> r <br /> TYPE OF7WOR.K (Check) : NEW WELL /7 DEEPEN / / RECONDITION /7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR L4PUMP REPLACEMENT /_7 <br /> Other <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 i. Cable Tool Dia. of Well Excavation <br /> - Domestic`/private .1 -- 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 /> .i1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done _.1 <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f: 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 /> i SIGNED 3 r 1Z TITLE �r� i <br /> r (DRAW PLUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYLVDATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT [INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY .' EDATE INSPECTION BY DATE 2 <br /> CALL-OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 <br /> E H 14i-6,_._ti 2 1M <br />