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f on 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:01,1,1c2 US L. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �.. <br /> (Complete In Triplicate) <br /> Application is reby 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 Ordin ce No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, <br /> O$ ADDRESS LOCATION CENSUS TRACT <br /> Own me Phone <br /> i <br /> Address (U� . <br /> City <br /> Contractor's Name . .License #,/ Phone r <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—Pump --REPLACEMENT /- <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK ZQ/=7-SEWER LINES JD A-PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 6 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing - 6 Y.2,• <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Z=2 994 <br /> Other Rotary -� <br /> - .,...,� Y Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H:P. ' <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: / J State Work Done <br /> F <br /> ,DFgTRUCTION 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- jo the bes of m knowledg Band belief. <br /> SIGNER <br /> TITLE <br /> {ARA LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY9 -- DATE 5� -- <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT NSPECTION P I FINAL INSPECTION <br /> INSPECTION BY . INSPECTION $Y DATE —f--.y-7 q <br /> CALL FOR A GROUT INSPECTION OR TO GROUTING AND FINAL INSPEC ION. �( i <br /> E H 1426 f�/71Y�. ��/ <br />