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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PFO!R40FFIC�E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> p� 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 Sart Joaquin <br /> County Ordinance No. 1862 and ;the Rules and Regulations of the San Joaquin Local Health District. <br /> / <br /> JOB ADDRESS/LOCATION CENSUS TRACT����� (��?�' � - --- <br /> Phone <br /> Owner's Name <br /> Address J / b City <br /> Contractor's Name License # /4�hone <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /� RECONDITION /7 DESTRUCTION /�'T <br /> PUMP INSTALLATION I I PUMP REPAIR I PUMP REPLACEMENT 17 <br /> Other I 1 <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 ' <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing 6` <br /> Irrigation Gravel Pack Depth of- Grout Seal. ' <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 5 <br /> I PUMP REPAIR: / State Work Done .,... <br /> ESTRUCTION OF WELL: Well 'Diameter , Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree ree 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 k wled and belief. <br /> AFf SIGNE _. TITLE <br /> (D W PI., T PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 11 �S �a <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -T 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L E H 1426 7/72�,IM <br />