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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. <br /> THIS .PERMI=T EXPIRES' `l `YEAR .FROM DATE ISSUED Date Issued Zf <br /> '(Complete in Triplicate) <br /> Application is -hereby'-t►ade' t the Sah Joaquin, Local Health District 'for a {pe'rt to construct <br /> and/or install the work herein described. "This application is made -in compliance with San Joaquin+ <br /> County Ordinance:'No:. 1862'--and: Oid"Ruies -and*Regulations of the Sari Joaquin -Local .Health• District. <br /> JOB ADDRESS/LOCATION CENSUS 'TRACT. . .� <br /> Owner's NariAe: . ,x � 'r rb `Phone <br /> Address City <br /> Contractor's Name { �• o �> s License !E / 3Phone 7l� <br /> s <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ PRECONDITION /_/ DESTRUCTION %�J �+ <br /> PUMP INSTMATION / / -PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> E DISTANCE TO NEAREST: SEPTIC TANK =6 SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> w W <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 S � <br /> Other Rotary Type of Grout <br /> f Other Other Information <br /> e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> State Work Done <br /> PUMP'REPAIR: s <br /> II ,)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f 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 /> j 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 ✓�YYt� '' TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> '. ADDITIONAL COMMENTS: <br /> f PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ 'DATE. /. -� "�?/ INSPECTION BY �/ DATE 2,,a :2-7-7?/_ <br /> CALL FOR A GROUT INSPECTION_.PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br />