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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> .1 Telephone: (209) 466--6781 <br /> APPLICA`T'ION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'�3�3�' <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 /> JOB .ADDRESS/LOCATION fly CENSUS TRACTb <br /> Owner's Name* ` ✓f Phone'a=Lll <br /> Address yy DCity <br /> Contractor's Name <br /> License ���p�L Phone <br /> i <br /> TYPE OF WORK (Check) :' NEW WELL _V DEEPEN '/ I RECONDITION I�! �DESTRUcTION %�T <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> Other ,/—/ — — <br /> DISTANCE TO NEAREST: SEPTIC TANi,_ ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4— Cable Tool" Dia. of Well Excavation <br /> 4-,-D'omestic/private Drilled Dia. of Well Casing lr _ <br /> Domestic/public 1,1 Driven Gauge of Casing <br /> Irrigation rGravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> Ali <br /> PUMP INSTALLATION: Contractor <br /> Type 'af Pump H.P. <br /> PUMP REPLACEMENT: / -7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DFgTRUCTION 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 f <br /> and the State of California pertaining to or regulating we11''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 /> 1 information is true to the best of my knowledge and belief. <br /> I <br />'i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY r� <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: *" <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL INSPECTION <br /> INSPECTION BY E, _,_11DATE 7.. / - INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �r 1426 5/731M <br />