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-ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160=1 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No. -f' <br /> THIS PERMIT EXPIRES -1 'YEAR FROM DATE ISSUED Date issued <br /> ,: ' (Complete In Triplicate) " <br /> Application is hereby' made' ta =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 theRu :.`and Regulations of the San Joaquin Local Health District. <br /> #; <br /> JOB ADDRESS/LOCATION � ; �• .- CENSUS TRACT <br /> , <br /> Owner's Name �f <br /> Phone <br /> Address <br /> "a City <br /> Contractor's Name �� <br /> ��� L cense # Phone <br /> TYPE OF WORK (Check) : NEW WELL .j/_ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION Z/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> — 3 <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 • <br /> Domestic/private Drilled Dia. of Well Casing T <br /> Domestic/public Driven Gauge of Casing 'f1 <br /> Irrigation Gravel Pack Depth of Grout Seal ! <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor e ^� <br /> Type of Pdmp H.P. _ 1 <br /> PUMP REPLACEMENT: State �— <br /> Work Done <br /> PUMP REPAIR: /—State Work Done <br /> 2ES_TRUCTION 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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well 'and notify them before putting 4wel- use. The above <br /> information is true to the best o,f my knowledge and belief. <br /> SIGNED � ' TITL(DRAW PLOT PLAN ON REVERSE S <br /> PHASE• I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO.GROUTING AND FINAL INS TION. �- <br /> E H 1426 7/72 1M Q0 <br />