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(14 'M JOAQUIN LOCAL HEALTH DISTRICI"O <br /> FOC. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. C� <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _�a3 tJ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and $egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION +L CENSUS TRACT <br /> Owner's Name Phone���' -t�Fy'� r <br /> N i � <br /> Address city <br /> Contractor N % License �1�83 L Co Phone —�3 <br /> TYPE OF WORK (Check) : NEW WELL Y DEEPEN / / RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / 0� <br /> DISTANCE TO NEAREST: SEPTIC TAMK,2b_l�_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI'S OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial4-- Cable Tool Dia. of Well Excavation <br /> __/-�ffiestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /a <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> Other Rotary Type of Grout s d—�? <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S-- +- H.P. _$ <br /> PUMP REPLACEMENT: / / State Work Done <br /> ' PUMP UPAIR: / / 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 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 SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �o2 `/ 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ',yam DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ` <br /> 5/731M <br />