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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi. Ol?� 1-C USE: 1601 E. Hazelton Ave, , Stockton, Cali <br /> f. <br /> . . � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?3 y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued z7 7_3 <br /> - (Complete In Triplicate) <br /> Application i hereby rude 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 Jbaquin .j <br /> County Ordinance No6, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Ong <br /> f ` CENSUS TRACT <br /> JOB ADDRESS/LOCATION -, !L, <br /> Owner's Name Phone <br /> City ' <br /> Address <br /> Contractor's Name _ Licensed Phone " <br /> 4 TYPE 0-F WORK. (Check): NEW WELL ( DEEPEN /Y/ RECONDITION_/ / DESTRUCTION /? <br /> PUMP INSTALLATION I� PUMP REPAIR '/ / PUMP REPLACEMENT /_7 �i J <br /> �C <br /> Other -/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK[66SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD IS" CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial _ Cable Tool Dia. of Well Excavation le <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing — I mo, _ <br /> Irrigation Gravel Pack Depth of Grout Seal a� <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor gS <br /> Type of Pump H.P. ' V <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Wk D v <br /> DFgTRUCTION OF WELL: Well Diame r Approximate Depth <br /> Describe M13al a d rocedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i 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 /> i FOR DEPARTMENT USE ONLY <br /> x <br /> PHASE I / <br /> APPLICATION ACCEPTED Ste/ DATE / a/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY T _ INSPECTI B_Y DAT <br /> CALL'FOR A GROUT INS TION PRIOR 0 G��AND FI INSPECTIO //1 "�`� <br /> 5/731M 1 <br />