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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> " Telephone: (204) 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 wade to the San Joaquin Local Health District for a permit to consu uct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance <br /> �No. 1862 an�.,Lil <br /> he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB/ADDRES/LOC 17 TIi�, CENSUS TRACT <br /> Owner's Name _ LD _ I Phone ( <br /> Address r'J . , ��c �r City <br /> Contractor's Name L _ License 1/121ClPhone7 �y-/3Y� <br /> c� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / j <br /> DISTANCE TO NEAREST: SEPTIC TANK/ _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ale Tool Dia. of Well Excavation / <br /> �Omestic/private Drilled Dia. of Well Casing /0 <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal -0-0 <br /> Other Rotary Type of Grout C<.-L c_-V _ <br /> Other Other Information <br /> PUV' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7- State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DFSTRUCTION OF WELL: Well Diameter Approximate Depth <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 <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 /> SIGNED 1� - TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROAT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY , DATE � �_ INSPECTION BY DATE <br />'! CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �W <br /> E H 1426 5/733.M <br />