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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —r-0 F. 06F ICE 3SE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> s R' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z!Ll-344 / ; <br /> .. t <br /> THIS PERMIT EXPIRES L 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 Regulations of the San Joaquin Local Health District. 1 <br /> Off- <br /> JOB ADDRESSILOC..ATION 3o CENSUS TRACT <br /> Owner's Name Phone sX I&/ �T 1 <br /> Address 1� � d d City A <br />-4-Contractor'_-s Name . c� 2�� License # Qa�l3 Phone ",g <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLI.IP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other I_/ <br /> DISTANCE TO NEAREST: SEPTIC TANK / / SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER e� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial T Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4a- <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Other X Rotary Type of Grout e� <br /> .. Other Other Information <br /> w <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DERTRUCTION 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 /> i 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 /> I 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 <br /> ,�.� TITLE <br /> � - <br /> (D PLOT LAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE BY DATE -- <br /> ADDITIONAL COMME <br /> P OUT INSPECTION P II NAL INSPECTI N <br /> INSPECT BATE ��-� INSPECT ATE � • <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />