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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> Fr—lor. OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6r - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,7- 2. 7cl <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamePhone <br /> Address C3 City <br /> Contractor's Name �� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ f RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION j / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other 17 <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 per, <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 j <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 `ZEPAIR: / / State Work Done <br /> i <br /> .DF9TRUCTION OF WELL: Well Diameter Approximate Depth Lalli wrr+ <br /> Describe Material and Procedure �yr <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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />_ADDITIONAL CO:=,NTS: <br /> PIiASE II GROUT INSPECTION PHAS II F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -T� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> C <br /> E H 1426 5/731M i <br /> a -a <br />