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D 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. r] <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED Date Issued �3 <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 andLIthe Rules and Regulations of the�SanJoaquin Local Health District. <br /> JOB ADDRESS/LOCATIO <br /> CENSUS TRACT <br /> Owner'6 Name Phone <br /> Address a`d <br /> Contractor's Name �� .e1 -_ <br /> .� �v License 4#,�,�'�Q�(� Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN / / RECONDITION /7 DESTRUCTION /-7. ` <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /Z�- <br /> Other / f -- <br /> 1 <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 f Cable Tool Dia. ' of Well Excavation � <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal +� <br /> Other i Rotary Type of Grout <br /> 1 Other Other Information <br /> 1 <br /> PUMP INSTALLATION: Contractor �t <br /> Type of Pump r H.P. !' <br /> I L-11 <br /> PUMP REPLACEMENT: /r/ State Work Done '_ <br /> PUMP REPAIR: f / J State Work Done <br /> PESTRUCTION 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 <br /> after completion of my work onla 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 we n use. The above <br /> information is true the best of my knowledge and belief. <br /> SIGNED - TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / ., lJ2 DATE C) <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BYDATE - '- 7- <br /> CALL FOR A GROUT INSPECTIONPRIORTO GROUTING AND FINAL INSPECT65N. <br /> E H 1426 11 7 A-r " ° 7/72 1M <br />