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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?g6V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued;r. <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 <br /> /and Regulations of the San Joaquin Local Health Distract. <br /> .TOB ADDRESS/LOCATION / 3 �' �T CENSUS TRACT <br /> 9 <br /> Owner's Name Phone + <br /> Address f <br /> City � <br /> Contractor's Name 1` License Z Phone <br /> TYPE OF WORK (Check): NEW WELL / PEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION �-- MP REPAIR-/—/ PUMP REPLACEMENT /7 <br /> Other / / — <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 4---Ea'S1e Tool Dia. of Well Excavation / \ <br /> ^A==—Homestic/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 _ �9- r - <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 C <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE " <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �� f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:.,, ,[ s <br /> PHASE GROUT INSPECT 0 PHASE III/FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE t" I <br /> CALL FOR A GROUT INSPECTION PRIOR TO OUTING AND FINAL INSPECTION. ! <br /> E H 1426 7/72 1M <br />