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mer / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ((V// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <br /> (Complete In Triplicate) DSI--flo-01 ; <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J4BADDRESS/LOCATIOIQ - ENSUS TRACT <br /> Owner's Nath _ p Phone <br /> Address Cit , { <br /> Contractor's Name License # .27 Phone -� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_� RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <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 <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other In .ormation N <br /> PUMP INSTALLATION: Contractor <br /> Type of mp H.P. / - <br /> PUMP REPLACEMENT: /tate Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��� _ _ DATE <br /> ADDITIONAL COMMENTS: — <br />�: PHASE II GROUT INSPECTION PHASE III/FILIAL INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY DATE / S"J' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M � <br />