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M1 <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_0r-7OFF1(E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� � Jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . /1�7Z � <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . Q d . .CENSUS TRACT ' <br /> — <br /> owner's Name Phone <br /> Address ZOD1 City ' <br /> Contractor's Name cense # /� X91 Phone v34Y <br /> -33 413 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ I RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> PUMP INSTALLATION: Contractor <br /> F 17E 2q hW <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: /State Work Dane <br /> PUMP `tEPAIR. / / State Work Dane <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 /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 11 APPLICATION ACCEPTED .BY �� DATE. <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT N <br /> INSPECTION BY 1 DATE INSPECTION BY DATE 6 2 Z <br /> F'OR�A GROUT INSPECTION -PRIOR,TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />