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__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 01'1iTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 126-1 fsp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X16 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name epl . Phone <br /> Address ,� City Q _f <br /> Contractor's Name License ��/9�oD Phone 0-7(y i36 <br /> TYPE OF WORK (Check) : NEW WELL /! DEEPEN '/—/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLAC�EMET /7 <br /> Other IV <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 4j <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public T Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> T Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFIZTRUCTION 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 />'E information is true to the best of my knowledge and belief. <br /> SIGNED ,� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> APPLICATION ACCEPTED BY DATE 2ZI <br /> ADDITIONAL COMMENTS: '- <br /> PRASE II ROUT INSPECTION PHASE IIx/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />