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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T3__/�ri �1 <br /> THIS PERMIT. EXPIRES l 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 /> County Ordinance No. 186.2 and thea es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONJWL CENSUS TRACT 06S--!?0--4-T <br /> Owner's Name Phone <br /> Address City <br /> � _ ��� <br /> Contractor's Name License �6 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYP ., OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing Poe <br /> Domestic/public Driven Gauge of Casing Qla <br /> �. <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: /J State Work Done <br />,DESTRUCTION_ OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL RS REPORT of the well and notify them before putting the well in use. The above <br /> infor do is true to the b st of my knowledge and belief. <br /> SIGNED �:� TITLE �vt� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �, <br /> APPLICATION ACCEPTED BY DATE` -`�--) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPSCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ,3 Z INSPECTION BY DATE 7-/ -7�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />