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Zd/ SAN JOAQUIN LOCAL HEALTH DISTRICT ~ <br /> FOR OFVICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NA T <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 San Joaquin <br /> County Ordinan�cA No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION 0,1' t-) 9 &2&:� CENSUS TRACT 017_oVO-ZJ <br /> Owner's Name Phone <br /> Address �� <br /> � -�� �.... city <br /> Contractor's Name License Phone : # ' <br /> TYPE OF WORK (Check): NEW WELL _/' DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 - -- <br /> PUMP INSTALLATION / PUMP REPAIR /_/ PUMP REPLACEMENT /7 <br /> Other / / — 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK �` SEWER LINES PIT PRIVY r� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER cc�� <br /> Aa ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> x Industrial ; Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing p-�P <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _r�,. �; �- _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor / J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done y , <br /> _ z <br /> PUMP REPAIR: / / State Work Done <br />, }E_S_TRUCTION OF WELL: Well Diameter Approximate Depth -r <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 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 7-1 <br /> (DRAW PLOT PLAN ON REVERSE S.ID ) <br /> FOR EPARTMENT USNLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� .i_ .�� DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE-III SINAL INSPECTION <br /> INSPECTION BY DATE ;� INSPECTION BY DATE ,.� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />