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SAN JpAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> is APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �' <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> 541 <br /> JOB ADDRESS/LOCATION to 1 . _, CENSUS TRACT <br /> Owner's Name Phone <br /> Address i9 City <br /> i Contractor's::Name _ — License # Phone <br /> .9 <br /> TYPE-OF WORK'�(Check): NEW`WELL /� DEEPEN /� pRECONDITION /� DESTRUCTION f�T <br /> PUMP INSTALLATION / / PUMP 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 /> I! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other _ Other. Information <br /> r PUMP INSTALLATION: Contractor <br /> • . Type of Pump H.P. <br /> n <br /> i3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> t PUMP REPAIR-' State. Work Done . <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 <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 wiil 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 /> r t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I,! <br /> APPLICATION ACCEPTED BY DATE 1411217 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INVECTION PHASE III/FINA1, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY — _ DATE //-f6-Z, �- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 IM <br />