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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> irWi.**OFFlCE1 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _Zp, -2 <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 CENSUS TRACT <br /> Owner's Name 0 f Phone <br /> Address N4 6`' xv- City <br /> Contractor's Name License Pho <br /> TYPE OF WORK (Check): NEW WELL IV DEEPEN RECONDITION /—/ DESTRUCTION /-7 -7 <br /> PUMP INSTALLATION Al PUMP REPAIR PUMP REPLACEMENT <br /> Other / 7 <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 Cable Tool Dia. of Well Excavation I t <br /> -:: /Domestic/private yDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -J�- <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 Work Done <br /> PUMP UPAIR: State Work Done <br /> ,DFqTRUCTION 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 SI <br /> F2E. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASF, II UT INSPECTION S;N-,Zl "A' INSPECTIO�V <br /> �HA I"' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -4 <br /> CALL FOR :��48"RU )FECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 600�f 5/731M <br />