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'Ott) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Phone <br /> .CEJ ,...s .� �� <br /> Address <br /> City <br /> Contractor's Name License #/&&0- Phone <br /> TYPE OF WORK (Check): NEW WELL PENS/ / RECONDITION /-7 DESTRUCTION <br /> PUMP INSTAL7.ATION /V PUMP REPAIR /—/ PUMP REPLACEMENT / <br /> Other / / — --7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHERlj&i����(,VjV <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 /> ---- <br /> PUMP INSTALLATION: Contractor oe <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1)-4:T State Wor Done <br /> PUMP REPAIR: /% State Work Done <br /> Approximate Depth <br /> ,DESTRUCTION OF WELL: Well Diameter ' <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 w <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 TITLE <br /> (DRAWep <br /> PLOT PLAN ON REVERSE SIDA " <br /> IT <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -- � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P �F F AL INSPE <br /> CJID <br /> INSPECTION BY DATE INSPECTION BYATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />