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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i'Of."OkF10E USE: .1601 E. Hazelton Ave. , Stockton, Calif._ <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-35~ <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1 S_ -s— <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 Sari Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local health District. <br /> JOB ADDRESS/LOCATION o Z20e,12CENSUS TRACT <br /> ' Owner's Name Phone <br /> Address [$� Z (� L� �la�� 0 L _ city ' '/- J <br /> j <br /> Contractor's Name License Phone 4r&/4e <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN �/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ./ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> FIELD CESSPOOL SEEPAGE PIT OTHER <br /> SEWAGE -DISPOSAL / ` <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 ., H.P. 3' <br /> PUMP REPLACEMENT: � State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> Z <br /> DF'ZTRUCTION OF WELL: Well Diameter Approximate Depth <br /> v <br /> F 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 PLM PLAN ON REVERSE SIDT) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (� <br /> APPLICATION ACCEPTED .BY DATE <br /> ,2 <br /> ' ADDITIONAL C0101ENTS: <br /> PHASE II GROUT INSPECTION PRASE II /FINAL INSPECTION <br /> INSPECTION B)F DATE INSPECTION BY DAT <br /> CALL FOR A -GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. kt <br /> E H 1426 - 5/731M <br />