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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 .6 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 _�� CJI�FfS yyUdY� ?Z CENSUS TRACT S 2 ' <br /> Phone <br /> Owner's Name _ <br /> . City ' <br /> Address <br /> License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL '// DEEPEN / I RECONDITION I� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERCA <br /> O <br /> ION SPECIFICATIONS <br /> CONSTRUCT <br /> INTENDED USE TYPE OF WELL . <br /> Industrial Cable Tool Dia. of Well Excavation CA <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5 <br /> Other Rotary Type of Grout <br /> Other _ Other Information Vs, <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / . / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> ` DESTRUCTION 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 s true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> .ADDITIONAL COMMENTS: pHAS III FINAL INSPEC •ION <br /> PHASE II GROUT INSPECTION INSPECTION B DATE <br /> :22- <br /> INSPECTION BY . DATE <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I SP TION. 4/72 <br /> E H 1426 <br /> - - <br />