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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICEi9? 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� r <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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,appiication is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 �.,t�e Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's Name , C <br /> AL- Phone <br /> Address <br /> City <br /> Contractor's ,Name �L J <br /> Licen'se .fv� Phone <br /> __ <br /> TYPE OF WORK '(Check): NEW WELL / / DEEPEN / J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE 'TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -; SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .INTENDED USE TYPE OF WELL 5 CONSTRUCTION SPECIFICATIONS <br />-- Industrial Cable Tool Dia. of Well Excavation- S <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing,, .. <br /> Irrigation Gravel Pack,- Depth of Grofit Seal <br /> Other ' <br /> "`- � W � �,-.....---�-- _ _. _ <br /> --- 'Rotary h"` ' Type' of 'Grout <br /> Other Other Information <br /> PUMP INSTALLATION:Z Contractor <br /> Type of Pump ' <br /> H.P. <br /> PUMP REPLACEMENT: /C. State Work Done <br /> ter-'" '; � /� �N • <br /> PUMP REPAIR: / / State 'Work Done - R <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State "of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />+TELL DRILLERS REPORT of the well and notify them before putting the we11. in use. The above <br /> Lnformation is rue toZ <br /> best of my knowledge and belief. <br />;IGNED <br /> 6 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br />'RASE I <br /> XPLICATION ACCEPTED BY DATE "A' <br /> 1DDITIONAL COMMENTS: ,s Z <br /> PHASE IIROUT INSP CTION P E I F ' INSPECTION <br /> INSPECTION BY DATE INSPECTION BY_' DATE - 7 <br /> CALL FOR A GROW INSPECTION, PRIOR TO GROUTING AND FINAL INSPECTION. ~ <br /> E H 1426 7/72 1M <br />