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'L SAN JOAQUIN LOCAL HEALTH DISTRICT ( <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (269) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permitto. —7 2 <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 /> :W <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS-TRACT <br /> Owner's Name Phone <br /> Address <br /> City. <br /> Contractor's Name 10 <br /> ._.��r�.,� - .•_ License # § hone <br /> l <br /> TYPE OF WORK (Check): NEW WELL /_+ DEEPEN}/_� RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT /—T <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY., <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE _PIT OTHER <br /> INTENDED USE TYPE OF WELL :� .� @ p CONSTRUCTION SPECIFICATIONS <br /> � <br /> I"" = t CATIONS <br /> Industrial <br /> Cabld`Tool Dia, of Well Excavation <br /> -- Domestic/private ' Drilled Dia. of Well Casing <br /> Domestic/public Driven �` #Gauge :of Casing <br /> IrrigationGravel Pack * Depth of Grout' Seal + <br /> Other � -� <br /> Rotary Type':of Grout' <br /> Other Other°Information <br /> PUMP INSTALLATION: Contractor i C)" ' <br /> Type of Pump ¢ <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done � # k <br /> PUMP-REPAIR: / / - -State Work Done - f Y - J ° <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations .'lof 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 TITLE A <br /> (DRA PLOT' PLAN ON REVERSE SIDEr # <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ---7- --orc <br /> PHASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r�� <br /> CALL FOR A GROU INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />