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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FOF..01'.A�IC�: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: # <br /> P {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Dace Issued 3 <br /> (Complete In Triplicate) _ --- <br /> 2s�cj <br /> -- <br /> Application is hereby made to the San Joaquin Local Health District dor �permit to constructI <br /> and/or install the work herein dasciribed. ' This application is made in compliance with San Joaqui' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District, <br /> �r l Z gip~ RES r yY <br /> JOB ADDRESS/ioCATION - � / , <br /> CENSUS TRACT <br /> i <br /> Owner's Name <br /> Phone <br /> Address �y �� <br /> city <br /> Contractor's Name ate_ ?�,� D <br /> License # <br /> Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK ls'? 1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER ^. <br /> INTENDED USE TYPE OF WELL -4 CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation �C5 <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 Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : <br /> H.P. ' - <br /> PUMP REPLACEMENT: / / State Work Done { <br /> PUMP UPAIR: "_� " "_ �"` <br /> D <br /> /�/ State Work""" one .._.' .�".��". w----- -- --•--- =-�:. <br /> ,DFqTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree, to comply with�all laws and regulations of the San Joaquin Local Health District a <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 ' true to the best of my knowledge and Relief. <br /> SIGNED TITLE l�,r•�-�-� �/ �7'f�"'�`� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY DATE a`ZS <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION { <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE,.:�-„2.-C -7!�' ; <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. am— <br /> E H 1426 <br />