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. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif„ <br /> Telephone: (209) 466-r6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26�j <br /> THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED Date Issued f-1 <br /> _-_73 <br /> Application is hereby made to the San (Joaquin eTriplicate)In <br /> 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 <br /> � CENSUS TRACT <br /> Owners Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name �. License # Phone { <br /> I i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /V,f` 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 v <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS �Cd <br /> Industrial Cable Tool Dia. of Well Excavation Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation � <br /> _— g ravel Pack Depth of GroutSeal i <br /> Other Rotary Type of Grout y r <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump } <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> — <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the ;an Joaquin Local Health District i <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 /> SIGNET} TITLE <br /> NJ <br /> 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY y <br />?RASE I <br /> APPLICATION ACCEPTED BY -7 <br /> LDDTTIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT ISP <br /> NECTION f{f <br /> PHASE FIN INSPECTION f <br /> ENSPECTION BY DATE It' INSPECTION BY ATE Z ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7172 1M 4 <br />