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SAN 1JOAQftN LOCAL HEALTH DISTRICT a <br /> FOR OFF E USE: 1601 E. Hazelton Ave. , Stockton, Cali-f. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU11P 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 /> :end/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and/the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION c J �G ( r ��Z �' r CENSUS TRACT <br /> f <br /> owner's Name ZC—rZ a f Phone�(� ��J"` 1 <br /> Address ( fl �G/(C� It r City <br /> Contractor's Name �I� � l l C� Q<'1 License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_ DESTRUCTION <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT I�T <br /> Other- / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Qj <br /> l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4A <br /> G Industrial Cable Tool Dia. of Well Excavation rr <br /> Domestic/private Drilled Dia. of Well Casing C <br /> _ Domestic/public Driven Gauge of Casing " <br /> Irrigation Gravel Pack Depth of Grout Seal 22 <br /> Other Rotary Type of Grout G /Y11-X <br /> Other Other Informati n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> r 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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE r <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1173 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GRQUT SPECTIO PHA II INAL INSPECTIO <br /> INSPECTION BY DATE �0-2T' INSPECTION BY DATE �D 3 <br /> CALL FOR A GROU INSPECTION PRIO TO UING AND FINAL INSPECT N. <br /> E H 1426 ?/72 1M <br />