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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOR OFFItE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ry <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71l- <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 an Regu ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT I <br /> Owner's Name Phone y <br /> Address City <br /> Contractor's Name - `� License <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION f-1 DESTRUCTION /- <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other r / <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 of Casing _ / T <br /> Irrigation Gravel Pack Depth of Grout Seal 6-0 <br /> Other _ � Rotary Type of Grout <br /> Other Other Information 1 <br /> PUMP INSTALLATIONS Contractor j <br /> Type of Pump H.P. <br /> 4 <br /> i <br /> PLUMP REPLACEMENT: / / State Work Done i <br /> _PUMP REPAIR: / / State Work Done j <br /> r <br />,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 /> 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 i true to the b st of my knowledge and belief. <br /> SIGNED l/!iG <br /> " 1 f � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I DATE <br /> ADDITIONAL COMMENTS: C <br /> PHASE II GROUT INSPECTION PHgE All F INSP I <br /> INSPECTION BY DATE _ INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. / v <br /> E H 1426 7/72 1M ! <br />