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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. T3/L 3 ,4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.?--2•,23 <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 i <br /> County Ordinance No. 1862 an the ules and R gut tions of the San Jo quip Local Health District. <br /> � � �.����-,�� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ Phone <br /> i <br /> Address _• CityIla <br /> Contractor's Name License #_'_??/X+e;� Phone 3�-Y-Y-,-1- <br /> TYPE OF WORK (Check) : NEW WELL/ /, DEEPEN / / RECONDITION /7 - DESTRUCTION /"7 ��- <br /> PUMP INST ATION / / PUMP REPAIR / / PUMP REPLACEMENT /� I <br /> Other / / x I ,Z <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 1 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor *► <br /> Type of Pump H.P. fi¢ <br /> r R <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 /> 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 �I <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 r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _.,]c�''7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA E III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY " DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . 7 <br /> E H 1426 4/72 IM <br />