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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POS OFFICE IIS'E: i' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 7, Telephone: (209) 466-6781 <br /> 3 HAPPLIC.ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k THIS PERMIT EXPIRES 1 XEAR,FROM DATE ISSUED Date Issued _4� _f Z1 � <br /> Complete In Triplicate) D <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 Joaquit <br /> County Ordinance No. 14862 and the Rules and Regulations of the San Joaquin Local Wealth District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT -- <br /> Owner's Name Phone <br /> Address 0 r <br /> f G City . <br /> L? J4, <br /> Contractor's Name k License <br /> TYPE OF WORK (Check) :Ii NEW WELL / / DEEPEN/ / RECONDITION/ I DESTRUCTION <br /> IIPUMP INSTALLATION / / PUMP REPAIR'/��PU►IP REPLACEMENT <br /> ,j _ <br /> : Other . <br /> i6 � ff <br /> DISTANCE TO NEAREST: " SEPTIC TANK SEWER LINES PIT PRIVY <br /> 11SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 11 'fY'l' <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable 'fool Dia. of Well Excavation <br /> Domestic/private er-Drilled Dia. of.Well Casing <br /> r Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack- Depth of Grout Seal � <br /> Other ai Rotary Type of Grout <br /> it Other Other Information " <br /> 11 <br /> PUMP INSTALLATION: " Contractor <br /> I� <br /> TYPe of Pump H.P. lm 0 . . <br /> I :w • <br /> #, PUMP REPLACEMENT: 11 / / State Work Done <br /> PUMP 'REPAIR: � � / State Work Done - <br /> DFRTRUCTION OF WELL: q Well Diameter Approximate Depth <br /> - II Describe Material and Procedure <br /> I <br /> F I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distx3c <br /> i <br /> and the State of California pertaining to or= regulating well 'construction. Within FIFTEEN DA7 <br /> after completion ofy work on a new well., I will furnish the San Joaquin Local Health District <br /> ? WELL DRILLERS REPORTiof 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 /> TITLE _ <br /> SIGNED - <br /> II (DRAW PLOT PLAN ON REVERSE E?� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED - DATE �"��/'� 7_5 . . <br /> ADDITIONAL COMMENTS s <br /> PHASE TI GROUT INSPECTION PHAE ITFINAL INSPECTION <br /> INSPECTIOBY _ '; -�_ DATE INSPECTION BY DATE <br /> N �r <br /> CALL FOR A GROUT-UNSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �� <br />