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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICC E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT' Peritiit, No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued af-Z3 <br /> (Complete In Triplicate) <br /> Application is hereby made to -the Salt Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein� desctibed. 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. i <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT _ <br /> Owner's Name Phone -671 <br /> � <br /> 9� <br /> Address - <br /> City <br /> Contractor's Name 7 License 4t Phone `` <br /> G� ��Y f <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /-7 RECONDITION 1-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> { <br /> DISTANCE TO NEAREST: SEPTIC TANK T SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <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 <br /> ._.. $ Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ✓ <br /> Contractor ,E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP REPAIR: j4=' State Work one Cha <br />.PESTRUCT.ION 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 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 <br /> TITLE C 2t re4 <br /> (DRAW PLOT PLAN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE lI GROUT INSPECTION # <br /> INSPECTION BY DATE INSPECTION BY ,�1 �/n�N DATEECTION <br />