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--- SAN JOAQUIN LOCAL HEALTH nISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton:-Ave.', Stockton, Calif. , <br /> Telephone (209Y4666-6781 c, <br /> APPLICATION FOR WELL, CONSTRUCTION+ OR PUMIP PERMIT Permit No. <br /> THIS PERMIT jEXPIRES� 1,YEAR FROM:DATE:ISSUED , k,' 'Date 'Issued <br /> 3 .(Complete In Triplicate) <br /> Applicatzon°z s hereby,:made. to th6oSanc.Joaquin-Local: Health District,forE`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 Tarid�:;the Rules{and :Regulations of -the,Sari- Joaquin;:Local Health District. <br /> �.. ! <br /> JOB ADDRESS/LOCATION <br /> CENSUS -TItACT'1S q <br /> Owner'sNamepPhone ' •. .r�. <br /> _ a <br /> Address <br /> City .. . .. <br /> Contractor`s Name License # Phone t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION J_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <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 /> .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 /> �1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> I <br /> PUMP REPAIR: <br /> / / State Work Done <br /> r <br /> ,DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - i <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 . 'r v TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> I <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: <br /> a I <br /> PHASE Il GROUT INSPECTION PHASE III/FINAL INSPECTION i I <br /> INSPECTION BY DATE INSPECTION BY ^�D DATE 2�, <br /> i <br /> CALL FOR AµGROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. F <br /> E H 1426 _. 4/72 1M . <br /> kkj <br /> F <br />