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X1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> YAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 de in compliance with San Joaquin <br /> County Ordinance No. 1 62 an/t � fan�eg, 6 a f de <br /> Local Health District. <br /> JOB ADDRESS/LOCATIO 6 o qh' 111 CENSUS TRACT <br /> Owner's Name , Phone <br /> Address l A'�._ C_._ City <br /> Contractor's Name 4.J License 32 3 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <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 w <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS -}L? <br /> Industrial �� Cable Tool Dia. of Well Excavation /'D <br /> �► _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Other Rotary Type of Grout r <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: f / State Work Done <br /> .pESTRUCTION 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 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 PLdTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE IS 7'y <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -1 - INSPECTION BY - DATE .Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br />