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AA <br /> f. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Or_OFF ICE USE: 1601. E. Hazelton- Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,. � l�J <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued .I <br /> (Complete In Triplicate) } <br /> Application is hereby made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described.. , This application is made in, compliance. with San Joaquin ,' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local fleal:th District. <br /> .SOB AD- DRESSILOCATION (j'K. S TRACT ; <br /> F <br /> � <br /> Owner's Name Phone <br /> City ' <br /> Address I S Q a <br /> ,� � ;)-3 t <br /> r License Phon <br /> Contractor's Name s <br /> (Check) --NEW WELL I I DEEPEN J / RECONDITION /_/ DESTRUCTION /� <br /> TYPE OF WORK (Check} . I <br /> PUMP INSTALLATION l�I PUMP REPAIR'/ I PUMP REPLACEMENT I� <br /> Other.1/ J <br /> 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 i Cable Tool Dia. of Well Excavation <br /> '/Domestic/private �ra:13-ed Dia. of We11 Casing �. - <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Sea] ` 1 <br /> Other Rotary Type of Grout_ 7 <br /> j Other Other Information <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump H.P. ' <br /> -P-U Nj 2_REPLACEMRN-T: - /-/-.,-State_Work-Done- <br /> PUMP"REPAIR: <br /> ,DFRTRUCTION 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 Californialpextaining to or regulating we1.l"construction. Within FIFTEEN DAYS L, <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District(y <br /> WELL DRILLERS REPORT of thelwell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I015-75 <br /> APPLICATION ACCEPTED .BY DATE a1� . <br /> ADDITIONAL COMMENTS: 6: P 5 II / ' AL INSPECTION <br /> P I GROUT INSPECTION <br /> INSPECTION BY r DATE -�- FNSPECTI DATE �1�3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5 l7�1M <br /> k T " l A 9 <br />