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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 4�FQR OFFICE USE: 1601 E. Hazeltori Ave. ,". Stockton, Calif. <br /> :` '' Telephoner ' (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION."OR PUMP PERMIT Permit No. � <br /> THIS PERMIT. EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued ' 77 <br /> 1 '(Comp-lets In Triplicate) <br /> Appficationr,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. 1861 and .the.-Rules" and Regulations _'61,, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT q �7 <br /> Owner,'a Name:: Phone <br /> Address -5'-- City . <br /> License # p. <br /> Contractor s Name ? / boa Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <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 '1 <br /> Other Other Information <br /> . r <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /—/ State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> t <br /> ;DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure E <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 TITLE <br /> f <br /> (DRAW PLOT PLANA ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z ��?�� ,,� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY , A DATE (—,/j` 7 <br /> CALL FOR A GROUT INSPECTION PRIOR,TO GROUTING AND FINAL INSPECTION. <br /> E i 1426 4/72 IM <br />