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f SAN JOAQUIN LOCAL HEALTH DISTRICT 'ftw <br /> Vit. 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 Issuedj�� <br /> (Complete In Triplicate) /z-�- 7`f' <br /> ,pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/or install the work herein described. , This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i0B ADDRESS/LOCATION '07 CENSUS TRACT <br /> haner's Name /> A� /.LCA " )�'. Phone <br /> -%ddress V <br /> City / r� <br /> 'ontractor's Name <br /> ense �f� � Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUREPAIR /j e—PUMP REPLACEMENT -7 <br /> MP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,�26 1 SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q , <br /> Industrial Cable Tool Dia. of Well Excavation oev <br /> Domestic/private Drilled Dia. of Well Casing 4 <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 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACErMNT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done - f`'E'• <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 /> jdELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information tr to the b st of my knowledge and belief. <br /> SIGNED t TITLE -4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO:Siu:NTS: <br /> PHASE II GROUT INSPECTION PHASE III IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC M1 e <br /> 3ig <br />