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k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> R THIS PERMIT EXPIRES' I YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 Sate Joaquin <br /> County Ordinance No. 1862 and the/Rules/and Regulations of the San Joaquin Local Health District. <br /> �J <br /> JOB ADDRESS/LOCATION V, CENSUS TRACT <br /> Owner's Name �/ ' ��ff/ �� Phone 9 �- <br /> Address �/' f City✓ <br /> Contractor's Name_ �_-A License hone <br /> I � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / I PUMP REPAIR REPLACEMENT f? <br /> Other / / <br /> f DISTANCE TO NEAREST: SEPTIC! TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION ,SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> //-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public € Driven Gauge of Casing Az <br /> Irrigation f Gravel Pack Depth of Grout Seal 14V C <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Wank Done <br />,.:.PUMP REPAIR, <br /> / / State Work Done <br /> ESTRUCTION 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 /> 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 /> SIGNE � <br /> TITLE <br /> [ DRA OT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I { <br /> APPLICATION ACCEPTED BY E <br /> ADDITIONAL COMMEN . <br /> P <br /> ��'j <br /> NTOPECTION <br /> INSPECTION BY 1z fflDATE INSPECTION E <br /> CALL FOR A PECTION PRIOR TO ROUTING AND FINAL I CT y <br /> E H 1426 7/72 1M <br />