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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION 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 :Wade 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 4Q6, �/�( fCENSUS TRACT <br /> Owner's Name -�. QLC /� / _�/� !� <br /> Phone 7�l <br /> Address Al. A119t- City e- o� <br /> Contractor's Name Tr• 5' /Z License # � Phone <br /> V <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /9- RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD — CESSPOOL/SEEPAGE 'PIT OTHER <br /> INTENDED USETYPE 0- WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> =omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �'Z <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: / / State Mork Done <br /> PUMP REPAIR: / / State Work Done <br /> J)ESTRUCTION 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 rue to a best of my knowledge and belief. <br /> SIGNED C <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID-E) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL IN TION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. r <br /> E H 1426 7/72 1M- <br />