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-g / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: g 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Y Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> d <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 Joa <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distri <br /> 11 <br /> JOB ADDRESS/LOCATION ' olfl 7 /L CENSUS TRACT S/J <br /> jOwner's Name Phone <br /> Address City <br /> Contractor's Name �.�n - ¢ License Phone 361rh�6� <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN / / RECONDITION /_� DESTRUCTION /7/� <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT �/ <br /> Other <br /> I — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE a TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven L Gauge of Casing <br /> Irrigation Gravel Pack C Depth of Grout Seal <br /> Other tl Rotary ,� Type of Grout <br /> " „- .Other NOiher Information <br /> B � 1 ♦ • h <br /> A l <br /> PUMP INSTALLATION: Contractor c� ��_ _J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR:\, /r state'Work Done, , <br /> ipESTRUCTION 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 DAY: <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of1the 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 /> h <br /> .SIGNED �j / TITLE <br /> ti (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY B DATE INSPECTION BY DATE -/f- 7 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />