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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F F OFFICE USF:: 01 E'. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.y <br /> 44&) <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 and Regulations of the an Jo4Quin Local Health District. <br /> JOB ADDRESS/LOCATION,�S� � f - NSUS TRACT <br /> Owner's Name .� r~ Phone <br /> Address .2/d 70 City <br /> Contractor's Name _ _ - _ ,License # Phone- � <br /> TYPE -OF WORK (Check): NEW WELL 471 DEEPEN '/J RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION J J PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other — — <br /> DISTANCE TO NEAREST: SEPTIC TANK /2 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G1 <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 , / ,6—AtA r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done T F <br /> PUMP 'tEPAIR: / / State Work Done <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 /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i information is true to the best of my knowledge and belief. <br /> SIGNED s TITLE <br /> ( W <br /> PLOT PLAN ON RE RSE SIDE) <br /> t 0 PARTMENT USE ONLY <br /> R PHASE I <br /> APPLICATION ACCEPTE Y DATE <br /> ADDITIONAL COIr�S <br /> PI GUT INSPECTION P I NAL INSPECTION <br /> INSPECTION DATE INSPECT DATE �Zf� <br /> CALL FOR A GROUT INSPECTION PRIOR TOOUTING AND FINAL INSPECTION. i <br /> E H 1426 5/731M <br />