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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1b01 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMT PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR DATE`ISSUED .f Date Issued i 73 <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 with San Joaquin <br /> Rules and Regulations of the San Joaquin Local Health-District, <br /> County Ordinance Na. .1$52 and the i <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone" <br /> Owner's Name <br /> Address <br /> �p � ..� � City <br /> _ <br />{ <br /> Contractor's Name ,1 <br /> License # ,) Phone <br /> t <br /> f _ <br /> _...i <br />—TYPE-OF WORK (Check). NEW WELL'ISALI DEEPEN. /Y-/-.-RECONDITION I_�� DESTRUCTION- -J� -- <br /> i PUMP` INSTLATION REPAIR f PUMP REPLACEMENT I�T <br /> Other <br /> I, DISTANCE' TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �- CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE � TYPE OF WELL � <br /> Industrial Cable Tool Dia. of Well Excavation �-. . <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge o£ Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 1 Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' .� <br /> H.P. <br /> Type of Pump - 0 <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done � .i w .,C,? <br /> Ap- - - <br /> - — �_ - proximate <br /> 1 " ,PESTRUCTIONI`0�' WELL: We-11 Diameter <br /> Describe Material and Procedure <br /> 1 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 :i <br /> 1 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 - TITLEe <br /> (DRAW PLOT P AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> € PHASE IDATE A�, <br /> APPLICATION ACCEPTED BY f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION AS TII/FTN INS <br /> PECTTO <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> CALL FORA_ GROUT INSPECTION PRIOR TO GROUTING AND FINAL Ti3SPECTI LM' <br /> 'I 4172 1M <br /> E H 1426 • : . <br />