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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.�3 7y <br /> THIS PERMIT EXPIRES l 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 Sant Joaquin. <br /> County Ordinance No.. 1862 and the R lee and Regulations of the San Joaquin Local Health District. <br /> ?-, <br /> JOB ADDRESS/LOCATION, G CENSUS TRACT <br /> Owner's Name 1 ' Phone <br /> Address. _:. s.. .. ... v_ ...,,.._ City / <br /> Contractor's Name. •c License # / 3 x Phone c47, 742& <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION / <br /> PUMP INSTALLATION �/ PbW REPAIR / / PUMP REPLACEMENT 1_7Other /_7 — <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 I <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 € _'k v H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP ' : x/ / -State Work Done- <br /> DFGT R ' <br /> UCTION OF WELL: Well Diameter �' <br /> . . ,. A roximateth <br /> De <br /> 'Describe Material and Procedure <br /> i <br /> IF I Hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Staterof California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wil.i furnish the San Joaquin Local Health District a . <br /> WELL DRILLERS REPORT 'of the well and notify them befo putting the well in use. The above <br /> infoMD <br /> is- true -to ,:the best of know:le e .a� .bel of.. <br /> :i <br /> SIGN LE <br /> (D 'W P OT PLAN .ON R SE SIDE), <br /> R DEPARTMENT U E ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY !J t - DATE 111171 <br /> ADDITIONAL COMMENTS; . r <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPE IO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL-FOR A-GROUT INSPECTION PRIOR. TO .GROUTING-AND.-FINAL INSPECTIO . <br />°"'-_ E H 1426. 5/731x4 _ 1 <br />