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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 'k 1601 E. Hazelton Ave. , Stockton, Calif. -- <br /> } Telephone: (209) 466-6781 �l <br /> `APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS 'PERMIT EXPIRES I YEAR FROM DATE ISSUED •Date' Issued � <br /> .(Complete In Triplicate) <br /> Application is herebymmade' to the San Joaquin Local Health District •€or a permit to construct <br /> and/or install the workherein described. This application is made in compliance"with San Joaquin <br /> County Ordinance No. 1862 and the -Rules •arid Regulations of the San Joaquin Isocal Health District. <br /> JOB ADDRESS/LOCATION , r CENSUS TRACT <br /> YaOwner's Name / Phone <br /> Address1-f I <br /> City <br /> Contractor's Name � License # f 7 <br /> ,11123-- Phone &Z-57- <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /j / PUMP REPLACEMENT /_" <br /> Other / / — <br /> I�N <br /> DISTANCE TO NEAREST: SEPTIC TANK ro SEWER LINES .. PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL '— <br /> • CONSTRUCTION SPECIFICATIONS Q � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public j Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal _ <br /> Other Rotary Type of Grout - - — . <br /> J Other Other Information <br /> PUMP INSTALLATION: d Contractor ` <br /> - _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / ir/ State Work bone <br /> iM .. <br /> PUMP REPAIR: .�/ {.State Work Done `1 7 �i - - ,jf �1 <br /> DESTRUCTION OF WELL: Well Diameter 9 <br /> Approximate Depth <br /> Dliscribe 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 /> WELL DRILLERS REPORT of the well and notifythem <br /> before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED U , TITLE <br /> �M14 (DRAW PL LAN N REVERSE SID <br /> 6 <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �(� <br /> ADDITIONAL COMMENTS: p <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY :IM DATE INSPECTION BY DATE �--- <br /> CALL FOR A GROUT INSPECTION PRIOR TO.-GROUTING AND FINAL INSPECTION. <br /> E H 1426 N 7/72 1M c <br />