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277 <br /> 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.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Sti <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 36 J'-,v <br /> Address / q CityL70L <br /> f # J Phone p <br /> Contractor's Name � ,� .f�' -� License !�/� X37 ��4 <br /> I <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /k / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 ,PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _• SEWER LINES 7 S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD--, r CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "V <br /> ..Industrial 7 ,_ Cable Tool Dia. of Well Excavation f O <br /> Domestic/private 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 /> Other Other Information <br /> S� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / T_ <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP REPAIR: / / State Work Done - — _ - - - <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 'A) DATE s��/s 7 L/ <br /> ADDITIONAL COMMENTS: ' <br /> f PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 1INSPECTION BY DATE It- 2 C/ INSPECTION BY DATE / <br /> k CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> r E H 1426 7/72 1M <br />