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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 he San Jo quin Loca Health District. <br /> 30B ADDRESS/LOCATION 7'363 �• � f� , <br /> CESUS TRACT <br /> Owner's Name Phone <br /> Address O �' City <br /> Contractor's Name License #/( 3 Phone <br /> TYPE OF WORK (Check): - NEW WELL / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION e PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /dbl SEWER LINES - 0 PIT PRIVY j <br /> ; SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CP <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 /> rz <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 1 <br /> f <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: & State Work Done <br /> Af <br /> 'PUMP""REPATRo" ""-" - " / /'? State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4 <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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUV_1*8PFtTI0VPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 2- j INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />