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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: (209)466-5781 <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 Sart Joaquin <br /> County Ordinance No. -1862 and. the- Rules and Regulations of the San Joaquin Local Health District. <br /> AJ'. CF- <br /> ! JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name i <br /> Phone <br /> Address City. <br /> Contractor's Name <br /> License # �"� Phone L46 -94�Zs <br /> TYPE OF WORK (Check) : NEW WELL ! / DEEPEN I I RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> C, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> - Industrial Cable Tool Dia. of Well Excavation tD <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 /> i <br /> I PUMP INSTALLATION: Contractor <br /> t - Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: = _ T - --S-tate-Work Done <br /> ESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k 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 /> E• 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 <br /> (DRAW PEOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY l� --� DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. Mb <br /> � E H 1426 7/72 1M <br /> - <br />