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y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Application is herebymade to (Complete In Triplicate) <br /> 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 /> JOB ADDRESS AOCATION <br /> 't CENSUS TRACT <br /> Owner's Name z - - <br /> Phone <br /> Address � � <br /> 7 �s�a City ' <br /> Contractor's Name ` a <br /> License # �_ Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /? RECONDITION /? DESTRUCTION /W7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK H 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 cl� <br /> Domestic/public Driven Gauge of Casing �1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Other _ - Rotary Type of Grout <br /> Other Y Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: # <br /> State Work bane i <br /> PUMP REPAIR,. , '- / State Work Done j v <br />,RESTRUCTION OF WELL: Well Diameter ° Y <br /> . 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, t <br /> SIGNED n TITLE <br /> f r <br /> (DRAW PEOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> € <br /> APPLICATION ACCEPTED BY j4 <br /> DATE p �� <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION P IP I F�N�INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND' FINAL INSPEC ION. ' <br /> E H 1426 7172 1M <br />