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K b , SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 6F. OFIICE USL: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A_�3DlJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-r-7¢ <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 <br /> oaquin _County Ordinance No. 1862 and thRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone lis <br /> Address v1 City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/I'DEEPEN -/_/ RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES PIT PRIVY — <br /> SEWAGE DISPOSAL FIELD p CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J2 <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: / f State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> ,DFRTRUCTION 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 BY DATE <br /> 1 IL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P If FI INSPECTION <br /> INSPECTION BY DATE INION BY DATE <br /> SPECT7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - - 5/731X <br />