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beQQ JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. <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 San Joaqui <br /> County Ordinance No. 18622 ander the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1al � /,I &{2L 1T.c�riA G X At,, Y4jI►✓ CENSUS TRACT <br /> Owner's Name Phone <br /> Address Q City <br /> He-- __ - � License IpPhone <br /> -- <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN / / RECONDITION J / DESTRUCTION /-7 <br /> PUMP INSTALLATION /Z- PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /T 'S1/vsP 2 / :Z1 i"- i1cr� r /l1 <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 Q <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 Information <br /> � t <br /> PUMP INSTALLATION: Caonctz - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DFgTRUCTION 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 + <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 /> t <br /> SIGNED i TITLE �C/17GO <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPART 44ENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY ,!Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT O'-7G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />