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. SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1,0F. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> _... Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L3-7 <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 Disprict. , <br /> JOB ADDRESS/LOCATION rr T/G CENSUS TRACT - <br /> Owner's ��� r <br /> Owner s Name / � Phone <br /> Address --- .J / Z� / City <br /> Contractor's Name CX _..License ��W' ��6.Z Phone <br /> TYPE OF WORK (Check): NEW WELL El�_ DEEPEN -/ / RECONDITION / { . DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / — --- <br /> DISTANCE TO NEAREST: SEPTIC TANK _J61Z SEWER*LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia, of Well Casing \ <br /> Domestic/public Driven Gauge of Casing t " <br /> Irrigation Gravel Pack Depth of Grout Seal----- <br /> Other <br /> Jr Rotary >. Type of Grout i 1 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP 'tEPAIR: / State Work Done 4 <br /> ,DF.RTRUCTION OF WELL: Well Diameter Approximate.. Depth <br /> Describe Material and Procedure i . <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the-State--of Calif-ornia 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-thea before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> PHASE IFOR DEPARTMENT USE ONLY <br /> y, ' '� � <br /> APPLICATION ACCEPTED .BY DATE 9 <br /> ADDITIONAL. COMMENTS: , µ <br /> .PHASE II gROUT-INSPECTION 1 PHASE-III/ INAL INSPECTION <br /> INSPECTION BY DATE ! INSPECTION BY � DATE <br /> CALL FOR A GROUT IN5PECTION. PRIOR TO GROUTING AND FINALINSPE ION.. <br /> 11 <br /> � <br /> F. F; 7L.7A <br />