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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL:OFFICE USL": 1601 E. Hazelton Ave. , Stockton, Calif. <br /> --�-`� Telephone (209) 46676781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 <br /> 1 (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 therein described: - This application is made in compliance with San Joaquin <br /> County Ordinance .No. 186.2 and the Rules and Regulations of .the San Joaquin Local Health lJistrict. <br /> I <br /> JOB ADDRESS/LOCATION:., CENSUS TRACT <br /> �� ► Phone <br /> Ovmer's Name <br /> City <br /> Address <br /> Contractor's <br /> Name rf }r License <br /> TYPE OF WORK (Check): I'NEW WELL / DEEPEN /_/ RECONDITION DESTRUCTION DESTRUCTION /? , <br /> PUMP REPLACEMENT /� <br /> 'PUMP'INSTALLATION / PUMP REPAIR € <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE LTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial T Cable Tool Dia. of Well Excavation <br /> i Domestic/private: tI�Drilled -Dia,-of,Well Casing <br />' x= �"Dzim`5tic:/`�i�iv is "y 'Driven Gauge o Casing W <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> E �M Other Other Information <br /> PUMP INSTALLATION: Contractor H,P. <br /> Type of Pump }' <br /> PUMP REPLACEMENT: °L/ State Work Done <br /> t� <br /> 'UMP �`tEPAIR: State -Work Done ` <br /> � / / � <br /> pFgTRUCTION OF WELL: Well Diameter <br /> Approximate De th <br /> I� D ii Matierial and Pr6'�edure <br /> 9� I hereby agree to comply- wit ail laws and regulations of a San Joaquin Local Health District <br /> and the State of California er-tainin$-t-o-or-.cregulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> E WELL DRILLERS REPORT of �tki 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 /> �� " TITLE <br /> SIGNED <br /> (DRAW PLQT PLAN ON REVERSE SID <br /> ' DEPAR T USE ONLY <br /> i <br /> PHASE I �. DATE <br /> APPLICATION ACCEPTED BY ' <br /> #' ADDITIONAL COM1,1E-NTS: p I /F , AL INSPECTI N <br /> PE I IGRO INSPECTWN DATE <br /> INSPECTION BY DATE 7 INSPECTION <br /> JJ` <br /> CALL FOR ROI INyyPF�TION•PR 0-2,-TO -GROUTING AND FINAL IN EGTI N. 5/731M <br />