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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. Z [L/$" <br /> THIS PERMIV EXPIRES 1- YEAR FROM DATE ISSUED Date Issued X2-3 <br /> (Complete In Triplicate) <br /> Application is Thereby ,made-to,-tht-I'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`land-the-Ru1e9 and-Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' rk— CENSUS-TRACT <br /> -77 <br /> Owner's Name' 9" _� p, rPhone <br /> Address .. �...._ City <br /> Contractor's Name _ - License # Phone <br /> i <br /> TYPE OF WORK (Check) :: NEW WELL /? DEEPEN 17 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION 10 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s INTENDED USE: TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> PUMP-INSTALLATION: "Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> a - <br /> PUMP REPAIR: / .J State Work Done Z, { <br /> ,DESTRUCTION 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 l <br /> and the Stgte •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 t best of my knowledge and belief. <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE - -- - •__._. <br /> .._ ._.__.. FOR :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 3 <br /> GALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. s <br /> 1M <br /> E H 1426 7172 <br />