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SAN JOAQUIN LOCAL HEALTH DISTRICT Z <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 //,--Y-7-�'- <br /> (Complete In Triplicate) <br /> Application is hereby made to "the San Joaquin Local Health District fora 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 a a <br /> / CENSUS TRACT <br /> Owner t s Name p,S'C� _ Phone <br /> Address , a City <br /> Contractor's Name %�_ �, License # Phone <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL /? 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Ik 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 t H.P. , . <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: State Work Done <br /> A <br /> 2ESTRUCTION 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 th a of my k-na edge and belief. <br /> I <br /> SIGNS _ . . TITLE <br /> (D W PLOT PLAN O REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS III FINAL INSPECTIO I <br /> INSPECTION BY DATE INSPECTION BY DATE t v € <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 7/72 1M <br />