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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> } <br /> Telephone:P (209). 466-6781 , <br /> r' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES- 1—YEAR, FROM DATE ISSUED Date Issued <br /> • (Coinple Fe In Triplicate) <br /> Applicatiarn�is.hereby made�to the SanfJoaquin 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 OrdinanceyNo:,"l$ <br /> and the Rules$and Regulations,,of the- San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO <br /> SUS TRACT <br /> Owner's t Name ,. �. Phone <br /> Address (� City <br /> Contractor's Nam <br /> .; <br /> A License Phone <br />= <br /> TYPE OF WORK .(Check): NEW WELL-/?,..DEEPEN'_ ./_-' .RECONDITION L7� DESTRUCTION, /7 . <br /> PUMP INSTALLATION PUMP REPAIR / % PUMP REPLACEMENT /7 <br /> Other / 7"� } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r� <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE FIT OTHER <br /> ago <br /> INTENDED USE <br /> _ 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 o€ Casing - op <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other ry -- Rotary Type of Grout n <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor F s <br /> Type of Pump R <br /> H.P. ' <br /> 'PUMP REPLACEMENT: / / State Work Done? <br /> . r <br /> ;PUMP REPAIR: /% State Work Done <br /> �--'- -. - <br /> }ESTRUCTION OF WELL: Well Diameter` Approximate Depth <br /> Describe Material and Procedure 4 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District n <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 r <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 knowledg and belief. <br /> SIGNED -,�. = r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) T <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 4 <br />:ADDITIONAL COMMENTS: DATE �.P-�73 <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE 4 <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />