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SAN JOAQUIN LOCAL HEALTH Di TRICT <br /> TO£.:OT'PICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ]PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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 Sant Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION 1L .7 �,l�,s L4 en .f -- -_ _ CENSUS TRACT ' <br /> C' 1 <br /> Owner's Name Phone <br /> Address City <br /> Contractor`s Name _,U c.c.n y�d - -- _ License ## AiZ` 73 Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / Pt,'MP REPAIR / / PUMP REPLACEMENT /7 <br /> Other l / <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \ 1 <br /> Domestic/public Driven Gauge of Casing V <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 H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUIIP U-PAIk: __. <br /> / / State Work Done <br /> ,DFRTRUCTION 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 on a 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 well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTIONS FVALF.INSPECT N <br /> INSPECTION BY DATE INSPECTIO Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I ECT OAT /~ <br />