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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For- OFFICES USE: 1601 E. Hazelton Ave. , Stockton, Calif. 3 <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,T <br /> - I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dat Issued /lo <br /> (Complete In Triplicate) I <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 Sant 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 Phone <br /> Address i City <br /> Contractor's Name License i`3��' -Phone7� /3 <br /> _ 1� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTIONS <br /> PUMP INSTALLATION / / PL`MP REPAIR / / PUMP REPLACEMENT=` /-T <br /> Other i`, <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 ---Gatte. Tool Dia. of Well Excavation E <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ][ H.P. <br /> PUMP REPLACEMENT: � <br /> State Work Done � <br /> PUMP `tEPAIR: / / State Work Done 1 <br /> ,DFgTRUCTION 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 Locai Health District a <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information <br /> -i-s —true to the best of my knowledge and belief. <br /> e <br /> { L J.�� _SIGNED TITLE ' <br />' (DRAW PLOT PLAN ON REVERSE SIDE .I1 <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I .. 4 <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OU INSPECTION PHASE IIT FINAL .INSPECTION <br /> INSPECTION BY DATE��n r Lf=7 INSPECTION BY DATE .16, 1< 4�._ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />