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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave: ; Stockton, Calif. <br /> j Telephone: (209) . 466-6781 <br /> APPLICATION FOR„WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_L 5 L <br /> THIS -PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED: Date Issued Y -fl 7 v <br /> (Complete In Triplicate) <br /> Application is hereby made to'j'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 andlthe Rules and Regulations of ,the San Joaquin Local Heal.th' District. <br /> JOB ADDRESS/LOCATION 16J CENSUS ,TRACT <br /> Owner's Name - .��. -� , .- Phone <br /> .: <br /> Address [1 City -.1 - --. <br /> Contractor's Name jT License # I� 37.3 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /`/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1_7 <br /> Other f/ / <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 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: / / State Work Done <br /> PUMP REPAIR: / ( State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - { <br /> Describe Material and Procedure <br /> t <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 /> i 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 PLM 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 PH&SE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO,-GROUTING AND FINAL INSPEC ON. <br /> -E H 1426 7/72 1M <br />