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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (204) 466--6751 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 J-1 o �p O/t CENSUS, TRACT <br /> Owner's Name Z 5 C1 C Phone, q j� <br /> C ` <br /> Address z z ' City =L=—� l�G� <br /> 1� <br /> ( /tf /1/f'l f/1 1 License 1��P ne <br /> Contractor's Name �U i�Z/ <br /> -0� � - <br /> TYPE OF WaRK (Check) : NEW WELL DEEPEN '/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE 0 'WELL CONSTRUCTION SPECIFICATIONS <br /> Dfidustrial _ Cable Tool Dia. of Well Excavation L <br /> omestic/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 Z <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE �Z <br /> ADDITIONAL COMMENTS: e <br /> PHAMII GROUT INSPECTION P III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 4172 <br />