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-1 11 L, <br /> eAN JOAQUIN LOCAL HEALTH DISTRICT; <br /> FOR OFFICE USE: 1601I,_ h- <br /> -Ne: <br /> Ave. , Stockton, Cal <br /> Telepho.e: (209) 466-6781 <br /> APPLICATION FOR WELL (:O.NSTRUCTION OR PUMP PERMIT Permit No. f__O al <br /> THIS PERMIT EXPIRES I yEE -',Z FROM DATE ISSUED Date Issued <br /> (Complete In Tripligate) <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. 1.862 .aild the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � . l CENSUS TRACT <br /> Owner's Name Phone <br /> t <br /> Address City <br /> Contractor's Name l�- �-; Licens- '�`� Phonea� •f7 <br /> TYPE OF WORK .(Check) :. . NEW._WELL--/Z .DiEPEN /� RECONDITION DESTRUCTION /_] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /77/ . <br /> r — <br /> DISTANCE TO NEAREST: SEPTIC TANK,: SEWEq,LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Uj <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation , <br /> 41--Vo-mestic/private Drilled Dia, of Well Casing <br /> Driven <br /> Domestic/public- - ----..-- --:----- ---.-_ - - -Gauge Casing <br /> _. . ._ IrrigationGravel—Pack- -- Depth---of- Grout__ al -- <br /> Other Rotary Type of Grout ► co., _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ?UMP REPLACEMENT: / / State Work-Done <br /> 'UMP REPAIR: /% State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> [ 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 /> :fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to t e best of my knowledge and belief. <br /> iIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> . _ FOR DEPARTMENT USE ONLY - --' <br /> 'RASE I .-- <br /> APPLICATION ACCEPTED BY DATE <br /> ►DDITIONAL COMMENTS: <br /> PHASE II GKOUT INSPECTIO P SE I FINAL INSPEC ION <br /> ' :NSPECTION BY DATE / INSPECTION BY DATE 3 5 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 717,) aw <br />