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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rEOEROEFFICEVUSE: 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 Issued21 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �Q S� t.�aa� CENSUS TRACT <br /> Owner's Name IV D r t��`7�. Phone <br /> s <br /> Address city ,r <br /> I <br /> Contractor's Name License # jW7j47hone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN / / RECONDITION /_� DESTRUCTION /? <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /�" <br /> AL � <br /> Other ul _AJZ r�,2t/I -x-- &,. � <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 (N. ' <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 pF <br /> PUMP INSTALLATION: Contractor <br /> ---- Type of Pump rte'n H.P. y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- / / State Work Done &40-R:j—� _ 1l~ _ �,��+�_ <br /> I� <br /> I ESTRUCTION 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 Distriet 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 my knowled e andNbelief. / <br /> SIGNED LE <br /> (D OT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR-A-GROUT`INSPECTION PRIOR TO GROUTING.AND FINAL INSPECTZ N. x/72 1M <br /> E H 1426 , <br />