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c II <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephones: (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES-1 YEAR FROM;DATE 'ISSUED Date Issued /j2) L- <br /> ;(Complete In Triplicate) : . ly. <br /> Applicationlisr_hereby made.- to .th-e 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 SanI. <br /> Joaquin <br /> County Ordinance No. x.862 an'd the Rules and Regulations of . ;the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION " 'CENSUS TRACT t <br /> Owner'•s. Name. ; �.� ,y Phon <br /> Address I <br /> _.. ... LL City . � Q,,� <br /> Contractor's Name <br /> ;Phoney .� Y <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN '/ / RECONDITION /? DESTRUCTION 1-7 �w <br /> : PUMP INSTALLATION / / PUMP REPAIR .I I PUMP REPLACEMENT f�j <br /> Other /V I ' f l a �s <br /> DISTANCE TO NEAREST: SEPTIC TANK,--j- SEWER LINES,EJ 4 PIT PRIVY g-_W S <br /> SEWAGE DISPOSAL FIELD OTHER <br /> NTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' �,� <br /> ^ i, <br /> Domestic/private Drilled Dia, of Well Casing I <br /> 'Domestic/public"" •'" '� Driven Gault of Casing`"'°" <br />._•- <br /> i-- <br /> Irrigation Gfdvel'-PAck— Depth of-Grout.-Seal.; _ I, <br /> Other 4. . Rotary f Type of Grout <br /> Other * Other Information + -5 n. <br /> PUMP INSTALLATION: Contractor I <br /> Type Of Pump I ti+ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />—PUMP'REPAIR: ' /7�7"s-tate`�Work"Done. <br /> .DESTRUCTION 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;kDAYS <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 true toa best of my knowledge and belief. II <br /> SIGNEDTITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' OR DEPARTMENT USE ONLY iV <br /> PHASE I a ii <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: { IM <br /> PHASE II GROUT INSPECTION 5HAS&III/FINAL INSPECTIONINSPECTION BY DATE INSPECTION BDATE , _L67ZCALL F'OR A GROUTINSPECTION PRIORTOGROUTING. AND FINAL INSION. <br /> E H 1426 . _ 4/72 1M`` <br />