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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE' USE: 1601 E. Hazelton'iAve. Stockton, Calif. <br /> Telephone.::. (203) :466.=6781- <br /> APPLICATION FOR WELL CONSTRUCTION.-OR PUMP PERMIT Permit No, z - 5 3 5 <br /> i <br /> THIS PERMIT !EXPIRES 1 YEAR �FR0�1-DATE ISSUED Date Issued - 7 v <br /> -(Complete,- In Triplicate) <br /> Application,Nis,hereby~made :to theLSan:.Joaquin1Local. Health District for a permit to construct <br /> and/or 'install the work herein described— This. application -is made incompliance with San Joaquin I <br /> County_Ordinance _No:'=°1862> and'v the Rules l•and -Regulations'of 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r, .�. r� CENSUS TRACT <br /> Owner's.'Name F r�� '- ., .Phone <br /> Address <br /> 4i1L9ci City <br /> Contractor's Name i d License # Phone { <br /> TYPE OF WORK (Check) NEW WELL / °yDEEPEN %/, RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other. / / k <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD `. CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4 Domestic/private Drilled Dia, of Well Casing fl <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRi State Work Done ��• � "� <br /> j ,DESTRUCTION:OF WELL: Well Diameter i` ` 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 /> and the Statie of California pertaining toor 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 f _ <br /> (DRAW PYOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY _ DATEj- j _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYGL DATE INSPECTION BY DATE <br /> CALL FORA GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 ; 4/72 IM <br />