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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ja ��2lJp <br /> f THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> /o�3i-7y <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / U <br /> CENSUS TRACT <br /> Owner°s Name ,�d Phone <br /> Address <br /> city <br /> Contractor's Name License Q hone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / RECONDITION /? DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION /)?/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia, of Well Excavation <br /> ,..W Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing a <br /> Irrigation Gravel Pack Depth of Grout Seal 6, <br /> Other Rotary Type of Grout A <br /> t Other Other Information ro <br /> PUMP INSTALLATION: p <br /> Contractor <br /> } <br /> Type of Pump <br /> H.P. <br /> PUMP State Work Done A14 q) <br /> PUMP REPAIR: / / State Work Done <br /> t <br />; ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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— nowl dge-and belief. <br /> SIGNE �� <br /> - �" TLE <br /> (DR�A PLO LAN ON V RSE SIDE <br /> PHASE I FOR DEPAR NT USE ONLY <br />€ <br /> APPLICATION ACCEPTED BY DATE t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIfFINAL INSPECTION <br /> INSPECTION BY DATE -INSPECTION BY _ DATE <br />` CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> E H 1426 <br /> 7172 1M <br />