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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TFF0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applj,cWtion is hereby made' to the San Joaquin Local Health District for a permit to construct <br /> and/Si install the work herein described. This application is made in compliance with San Joaquin <br /> Coutity Ordinance No. 1862 and the Rules and Re^gulati�o�ns of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION / J �4�✓ CENSUS TRACT <br /> Phone 731 ' <br /> Owner's Name <br /> - � City <br /> Address r Ir <br /> Contractor's Name License �Phone ' - ,z <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation IT\ <br /> fY 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 /> j Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wc6ODone <br /> PUMP REPAIR: / / State Work Done <br /> s ,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 /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> f 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 n <br /> f information is true to the best of my knowledge and belief. tc1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> do <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I =3`, DAT.P-� l�� <br /> APPLICATION ACCEPTED BY — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P " S AL INSPE2t-4 <br /> INSPECTION. 'BY DATE INSPECTION BY ATE{ CA <br /> LL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7172 1M <br /> E H 1426 <br />