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SAN JOAQUIN LOCAL HEA1TH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Califs <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIOW OR PUMP PERMIT Permit No. _� q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k (Complete In Triplicate) <br /> Application is hereb made t;o the. San Joaquin Local Health District for a permit to construct <br /> t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin 'Local Health District. <br /> k JOB ADDRESS/LOCATION <br /> -- CENSUS TRACT <br /> Owner's Name r. .. <br /> Phone 7 <br /> Address ` <br /> City <br /> Contractor's Name - License # .13-{ Phone ., <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION / DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other l/ <br /> DISTANCE TO NEAREST: SEPTIC 'TANKIlI SEWER LINES PIT PRIM, ~ <br /> SEWAGE DISP S IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLCORUC <br /> / <br /> Industrial NSTTION SPECIFICATIONS <br /> C � i{ able Tool Dia, of Well Excavation <br /> Domestic/private V Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 4 Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of PumpH.P. E <br /> PUMP REPLACEMENT: <br /> / / State Work Bone � <br /> PUMP REPAIR: <br /> / / State Work Done -0 <br />,DES_TRUCT_ION OF WELL: Well Diameter , <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply withall 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 REP T of the well and notify them before putting the well in use. The above <br /> information is a to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATEZ— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS II FI INSPECTIO <br /> INSPECTION BY DATE. INSPECTION BY DATE <br /> CALL FOR A GROUT .INSPECTION�PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H. 1426 s , 7/72 1M <br />