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/ SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> FOL:OF ICE .USE: 1.601- 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 ,2'.,t <br /> (Complete In Triplicate) <br /> Application is hereby rude 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 Sari Joaquin . <br /> County Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin Local Health Disprict. <br /> P <br /> F �. . <br /> JOB ADDRESS/LOCATION ` '� * r'--r ..CENSUS TRACT - <br /> Owner's Name Phone <br /> Address (), ZZ2 City 'd/JupLd/ `frPar�tj <br /> contractor's Name Gdt , License # &� Phone - <br /> 7/74 <br /> TYPE OF WORK (Check) % NEW WELL/ DEEPEN '/—/ RECONDITION f—/ DESTRUCTION I-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /- <br /> Other ---- <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> 1( SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 IL/4 <br /> j/ Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ //// Rotary Type of Groin <br /> Other Other Information -,6 <br /> PUDE' INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `PAIR: / / State Work bone. ` �- --• <br /> ,DFgTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all :Saws 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 Hearth 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 /> (D&W T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED /,7BY DATE -- /� <br />' ADDITIONAL CO10MNT <br /> PHASE II GROUT INSPECTION LAWI I/ NAL INSPECTION <br /> INSPECTION BY DATE 42:INSPECTI DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL INSPECTION. <br />