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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S=p2413 <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 Satz Joaquin <br /> County Ordinance, No. 1862 and the Rules and Reguiatio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' � SUS TRACT <br /> Owner's Name Phone y _ <br /> t <br /> Address ieZ City ' ' <br />(,,Contractor's Name. License���_ Phone 7 <br /> TYPE OF WORK (Check): NEW WELL '/ / DEEPEN '/ f RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATIO PUMP REPAIRio <br /> I I PUMP REPLACEMENT I� <br /> Other <br /> i <br /> DISTANCE TO N AREST: S IC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> r,A,�rigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump AoH.P. <br /> PUMP REPLACEMENT: /Z�;-State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter c A proxima D <br /> Describe Mat.4r" and /Pybe d e <br /> II -- � �• <br /> I hereby agree to comply with alr laws and regulations of the San Joaquin Local Health Di6trict � ,'r:4 <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 /> 4�_-, <br /> information is true to the best of, my knowledge and belief. <br /> SIGNED . _ _ _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) (r 100, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I14SPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r- <br /> 4 - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> R x '1426 5/731.M <br />