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USAN JOAQUIN LOCAL HEALTH DISTRICT 'y <br /> ` Stockton <br /> Calif.FOR OFFICE USE• `'1601 E. Hazelton Aver, s ,s,µ, <br /> Teleplione:Y (209)` 466-6781 ;. �� <br /> APPLICATION FOR WELV CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS'PERMIT`EXPIRES l-' YEAR FROM DATE ISSUED <br /> Tlate..-Issued.o2 / <br /> f = •(Complete In Triplicate) <br /> ct <br /> the. SanyJoaquin Local HeaonDistmade irict ntcompliancewa pe mit to ithnSanuJoaquin <br /> Application is hereby made` tci <br />{ and/or install the work herein described. 'This apPl.ic <br /> County Ordinance No. 186`2 and the Rubs and Re Mations of the San Joaquin Loca3 District. <br /> Health <br /> CENSUS TRACT 57 <br /> US- TRACT <br /> ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> Address <br /> City <br /> License # Phone f <br /> r Contractor's Name � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /� DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / rPUMP REPLACEMENT /-T <br /> Other / / <br /> is <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> INTENDED USE '' TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial q 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 /> PUMP INSTALLATION: :Contractor <br /> Type of Pump •P• _�_.. . <br /> PUMP REPLACEMENT: < / / State Work Done <br /> PUMP .REPAIR; / /- .State Work„Donle -_ - - - <br /> �'"-— <br /> I_ . <br /> Approximate Depth <br /> -DESTRUCTION OF WELL: '' Well Diameter <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 /> F information is true to the t of my knowledge and belief. <br /> TITLEG� <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 5!� <br /> FOR DEP MENT USE ONLY <br /> PHASE I DATE __ <br /> APPLICATION ACCEP BY <br /> , ADDITIONAL COMMENTS: p S I F AL INSPECTJON <br /> �� <br /> PHASE II GROUT INSPECTION ATE <br /> k INSPECTION BY DATE _ J INSPECTION BY _.. m <br /> CALL FOR A GROUT INSPECTION,PRIOR ,TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M �Ur� <br /> c <br /> L H 1426 <br />