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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. OI.ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2T 5j0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-/S-7( <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 Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION s CENSUS TRACT <br /> Owner's Name k' C _ Phone <br /> Address City . . > <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : - NEW WELL / / DEEPEN '/ / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES g PIT PRIVY <br /> SEWAGE DISPOSAL ELD CESSP L/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAME <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 <br /> Other X Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Rep. , <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP UPAIR: / / State Work Done <br /> ,DFITRUCTION OF WELL: Well Diameter Approximate Depth 25 <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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i, WELL DRILLERS REPORT of .the well and notify them before putting the wellin use. The above <br /> information is tr a to the best of my knowledge and belief. �4 <br /> l <br /># SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIB ) <br /> FOR DEPAR MENT USE ONLY <br /> i PHASE I •• ,.� � _� <br /> APPLICATION *ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . e <br />