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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 . OI�USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IF G /►/ CENSUS TRACT <br /> Owner's Name C a La Phone <br /> Address 2 /V City <br /> Contractor's Name ',.,C. License #2.1,s-76 <br /> r Phone 4,( 59j,2 <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN '/ / RECONDITION /—/- DESTRUCTION f_7 <br /> PUMP INSTALLATION / J PUMP REPAIR /% PUMP REPLACEMENT <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK C cr SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �p . <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. X <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: J / State Work Done <br /> DFgTRUCTION 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 wellconstruction. 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 /> SIGNEDe TITLE <br /> 1 - C - <br /> ----(-DRAW PLO AN ON REVERSE SIDE) <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY IC _� . V DATE <br /> ADDITIONAL CO141ENTS: <br /> PHASE II GROUT INSPECTION M.I� INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE v <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN / <br /> E H 1426 5/731M <br />