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W S(' jOAQUIN LOC�-%L HTALTH DISTRICT n . <br /> FOR OFFICE USE: 1601`_u. Hazelton Ave. , Stockton, Califs <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 .g// <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health DistricOculnee <br /> construct <br /> h work herein described. This application is made th San Joaquin <br /> and/or install the Pp <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W, L I° CENSUS TRACT I <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License J# Phone <br /> TYPE OF WORK (Check.) :. NEW WELL / f DEEPEN '/ / RECONDITION /_� DESTRUCTION, / <br /> ALJ <br /> PUMP INSTLATION / / PUtiP REPAIR / / PUMP REPLACEMENT S <br /> Other J% <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> qm <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump' S H.P. .� <br /> PUMP REPLACEMENT: / / State Work Done <br /> W l I <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION 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 /> atter completion of my work on a new well, I will furnish the San Joaquin Local :Health'J. )istrict a <br /> WELL DRILLER1. <br /> REP( of the well and notify them before putting the well in use. The above <br /> informati, is t o the best of my knowledge and belief. <br /> SIGNED i .T TITLE �,e.' <br /> (DRAW <br /> PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /^ Z 9�V <br /> ADDITIONAL COMMENTS: <br /> PHASF, II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY� DATE INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />