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ieO SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephorie: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , oi� <br /> .THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2.4y <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 ®y �� CENSUS TRACT � $ <br /> Owner's Name , e9 a, ry �zy�._.��„- Phone.- <br /> Address /' City �h1 � <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / 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 /> C <br /> INTENDED USE TYPE OF WELLy <br /> CONSTRUCTION SPECIFICATIONS �J <br /> Industrial Cable Tool Dia. of Well Excavation 4•J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal c <br /> Other Rotary Type of Grout 'S <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 <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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE TTI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE -,2 4/- <br /> .,-CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 91426 7/72 ll� <br />