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{ <br /> ` W v SAN JOAQUIN LOCAL HEALTH DISTRICT 46 <br /> FOL 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 made in compliance with Ban 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/�� 5_�7 r��� �1 /Yu�.. _- Phone <br /> Address ' � City % Ga <br /> Contractor's Name :��� ���C�7i�/_� ��_ -- License <br /> TYPE OF WORD (Check) : NEW WELL / / DEEPEN / / RECONDITION /—/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T&NIK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> A <br /> - Domestic/private Drilled Dia. of Well Casing 1tP` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> k <br /> f <br /> PUMP INSTALLATION; Contractor / <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> F DF5ZTRUCTION 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 REPO o the well and notify them before putting the well in use. The above <br /> information is a best of my knowledge and belief. <br /> SIGNED r - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI 4E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> YPLICATION ACCEPTED BY DATE &-2"" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE 'TION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />