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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: r / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S 3 <br /> ` ! THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) L t <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 JoaquA <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. : <br /> r <br /> JOB ADDRESS/LOCATION ,] CENSUS TRACT <br /> Owner's Name Phone <br /> Address ,. City <br /> Contractor's Name - - �--- License 4y7 .j < Phone 3 0 <br /> TYPE--OF WORK (Check) : NEW WELL T DEEPEN/ / RECONDITION / / DESTRUCTION /?� <br /> PUMP INST CATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /_7 <br /> — <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 <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 /> Type of Pump r—' H.P. <br /> r PUMP REPLACEMENT: / / State Work Bone <br /> PUMP 'REPAIR: / / State Work Done <br />�_ T}RcTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> 5 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 Hearth 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 Tay knowledge and belief. <br /> SIGNED TITLE z 111 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />} APPLICATION ACCEPTED .BY DATE <br />`r ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYE DATE f YINSPECTION BY T� �/ DATE <br /> CALL FOR A GROUT INSPECTION P iOR TO GROUTING AND FINAL INSPECTION. ,f <br /> E H142 6 ,(/ e o. „ccdj dr�O- ?/;t Pir-.Ab),r en.- <br />