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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 10E.OF ICL USE: 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 hereby rade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the, work herein described. ' This application is trade in compliance with Sar: Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 CENSUS TRACT ' <br /> Owner's Name + Phone <br /> Address P_�. G res City .T e0 e J j <br /> Contractor's Name License # I 2y, done <br /> TYPE OF WORK (Check) : NEW WELD. '/ / DEEPEN '/�/ RECONDITION /_/ 'DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMA' REPAIR /W—PUMP REPLACEMENT /_ <br /> Other 7_7 <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 E <br /> Domestic/private. , Drilled Dia. of Well.Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMA' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP UPAIR: State Work Done <br /> l ` V <br /> ,PFATRUCTION 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 m now . dge belief. <br /> SIGNE TITLErr- . <br /> PLOT' PLAN 4N R ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATES�Jl� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ILJ4EINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY ! DATE i <br /> CALL FORA.GROUT INSPECTION PRI0f -TD GROUTING AND FINAL INSPECTION. + <br />