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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. HazeltonAve.`, Stockton, Calif. <br /> Telephone:: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X1-5 <br /> THIS .PERMIT°'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ll=,l f (Complete In Triplicate) <br /> f Application is-hereby, nitia de` 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 -arid Regulations of the San Joa uin Local Health Distract. <br /> . :. . .,.; ..s . .c s._: .� ._. c <br /> JOB ADDRESS/LOCATION cry 6 Ccs CENSUS TRACT <br /> Owner's Name Phone' <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): <br /> NEW WELL / - DEEPENIM RECONDITION /_/ DESTRUCTION /-T <br /> ` PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> G Industrial _--eatTe Tool Dia. of Well Excavation <br /> _j..-Domestic/private Drilled Dia. of Well Casing G? <br /> ' Domestic/public Driven Gauge of Casing o <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> {t I� Other Other Information � , <br /> PUMP .INSTALLATION: !Contractor �� - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> j PUMP REPAIR: / L..State Work-Donee..._ <br /> ,RESTRUCTION OF WELL: 'Wi 11-Diameter _ Approximate Depth >_ <br /> Describe Material and Procedure <br /> i <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 /> information is true to� the best of.my knowledge and belief. <br /> SIGNED <br /> wll - TITLE �. <br /> �p (DRAW PLOT PLAN ON REVERSE SIDE] <br /> FOR DEPARTMENT DISE ONLY <br /> 1' PHASE I � - <br /> APPLICATION ACCEPTED aY SATE - <br /> ADDITIONAL COMMENTS: �0 <br /> PHASE II �GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY d! DATE INSPECTION BY DATE <br /> r CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND -FINAL INSPECTION. <br /> E a, 7172 1M <br /> H 1426 <br />