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�p P� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OF F;ICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. za,-/�� 1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ��6-7� <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 CENSUS TRACT <br /> Owner's Name <br /> Address�/ city ' ' <br /> Contractor's Name piL License hone6W <br /> a <br /> TYPE OF WORK (Check): -NEW WELL _V/ DEEPEN /_/ RECONDITION/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES !p @ PIT PRIVY— <br /> SEWAGE <br /> RIVY---SEWAGE DISPOSAL FIELD 100 CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private � 4- Drilled Dia. of Well. Casing CI <br /> Domestic/public Driven Gauge of Casing jj <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. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP "IEPAIR: / / State Work Dome <br /> ,DFfiTRUCTION 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 j <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 j <br /> information is true to .the best of my knowledge and belief. <br /> i <br /> SIGNED _ TITLE I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: 00I <br /> PHASE II GROUT INSPECTION P SE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE tO <br /> CALL. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br />�� E H 1426 5/731M <br />