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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR fyFFIC& USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3_ <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 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 2 <br /> .���. CENSUS TRACT <br /> Owner's Name. 12 s Phone <br /> Zai 7• <br /> Address <br /> 'moo city <br /> Contractor's Name _ 01dLN.�°�__. _ License # Phone <br /> TYPE OF WORK (Check):- NEWWELL /% DEEPEN /_7 RECONDITION DESTRUCTION /� -- <br /> PUMP INLATION-/ / PUMP REPAIR" / / UMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIITP IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1A <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> % Type of Pump <br /> �. H.P. <br /> J <br /> PUMP REPLACEMENPr: ;.aj State Work Done ox <br /> - <br /> .PUMP REPAIR: _ / :/, State-Work Done <br />.DESTRUCTION OF WELL: Well Diam�t r <br /> - -•- -- Approximate Depth <br /> Describe Mater 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 nay work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and ncAfy them before putting the well„in use. The above <br /> information is true o the best of my' knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE iI GROUT INSPECTION P E III FINAL INSPECTIO <br /> INSPECTION By, DATE � INSPECTION B DATE � <br /> CALL F' R A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H l�i2G 7/72 1M <br />