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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel ton...A've.. ,..Stockton, Calif. <br /> Telephone.': .- (209) 466--6781 <br /> APPLICATION FOR YELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT -EXPIRES 1, YEAR FROM DATE ISSUED • Date Issued <br /> '(Complete In Triplicate) <br /> Application is hereby m de#;ro the. San•. Joaquin' Local .Heal:th .District;for; a permit to construct <br /> t and/or install, the work herein described. This -application is• made.in compliance. with San Joaquir <br /> County :Ordinance No. . 1862 -and thel.Rules and Regu1Flations•of the' San Joaquin Local. Health District. <br /> r <br /> JOB ADDRESS/LOCATION � CENSUS TRACT ISA. <br /> Owner."s Name T, z A, <br /> r Phone <br /> Address <br /> City <br /> Con.tractor's Name !� 41 License Phone <br /> TYPE OF WORK (Check) : NEW WELL '// DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> tt DISTANCE TO NEAREST: SEPTIC TANK,50 10 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> 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 Rotary Type of Grout . <br /> Other r_OtH_e Information <br /> PUMP INSTALLATION: <br /> Conda ctor <br />' Typeof Pump �, ,., H.P. . <br /> PUMP REPLACEMENT: /—7 <br /> / / ' State Work Done <br /> PUMP REPAIR: / / iState Work Done. VV <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. i Within FIFTEEN DAYS <br /> after completion of my work on a new well:, I will furnish the San Joaquin Locaf'Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information r to the bestof my knowledge and belief. <br /> SIGNE c TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> . INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 4172 1M <br />