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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Pio'n, OFFI SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. c{(4 cd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> Application is hereby made. 'o the San Joaquin Local Health District for a permit to construct <br /> and/or ins-all 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 -6-/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> to <br /> Contractor's Name ° <br /> License # // Phone <br /> TYPE OF WORK (Check): NEW WELL b DEEPEN '/ / RECONDITION 1 / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT /-7 <br /> ,Other .l I <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 _ .1 a <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /� ? <br /> Irrigation Gravel Pack Depth of Grout Seal .S"U <br /> Other t: Rotary Type of Grout S,fi-yd,f r-49 A -70- <br /> Other <br /> .fOther Other Information <br /> n• 1 <br /> PUMP'�INSTALLATION: Contractor S:w <br /> S Type of Pump.' H.P. <br /> PUMP REPLACEMENT: / f State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> .DFRTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> I <br /> Describe Material and Procedure <br /> r � . <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Sate 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, s # <br /> APPLICATION ACCEPTED ,BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE S _ INSPECTION BY ' DATE -7 <br /> CALL FOR A GROU�INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />