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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z� <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. 18622 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION +] Hl-'�'i�' �.1� CENSUS TRACT <br /> V& <br /> rn doWr i r) 7 3 417 y <br /> owner's N�s�� �/-/��0lb0' Phone <br /> Address city � �" <br /> Contractor's Name License # d4laz Phone <br /> TYPE OF WORK (Check); NEW WELL / / DEEPEN /—[ RECONDITION /_7 DESTRUCTION /7 <br /> -PUMP INSTALLATION / f PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other / / <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 <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / % State Work Done �,� ��� t �L <br /> ESTRUCTION 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 t _ <br /> (DRAW FTOT PLAN ON REVERSE SIDEVJ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ef I� D A TE Y7 v <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHAVA , F NSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE —L-73(a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE T <br /> E H 1426 7/72 IM <br />