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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> ��vido p <br /> THIS PERMIT EXPIRES 1 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 application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health District. ? <br /> JOB ADDRESS/LOCATION QQ CENSUS TRACT i <br /> i <br /> { <br /> Owners Name7f Phoneme 7 / ti J <br /> Address 2L4 City <br /> ' !�� <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /7 DESTRUCTION X <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7Other Tr T <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge bf Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ' <br /> Othdr Other Information <br /> w- <br />, PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. V <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,pESTRUCTION OF WELL: Well Diameter o�imate Depth i <br /> _., <br /> Describe Material and Procedure <br /> T 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 i <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. p . <br /> SIGNEDT ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I a <br /> ' DEPARTMENT USE ONLY ! <br /> APPLICATION ACCEPTED BY PATE <br /> AbDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA INSPECTIO } <br /> INSPECTION BY DATE INSPECTION BY DATE ; <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />