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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466-67$1 7 <br /> PLICATION FOR ,WELL'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> L <br /> THIS PERMIT 'EKPIRES' l YEAR FROM DATE' ISSUED Date Issued �- <br /> (Complete In Triplicate) <br /> Application is .hereby •made'`to the -San•Joaquin Local Health Distract for a per Imit 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-'R61ee6 and Regulations of the San Joaquin•.'Local' Health Districts. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> IOwner's Name <br /> Phone" ' <br /> Address S <br /> City <br /> Contractor's Name <br /> License # 14 IM Phone _ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /? RECONDITION /_ DESTRUCTION <br /> _ I <br /> PUMP INSTALLATION _/ / PUMP REPAIR /p�( PUMP REPLACEMENT /? <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTIC "TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . i. Cable Tool Dia, of Well Excavation <br /> Domestic/private ! Drilled Dia, of Well Casing W <br /> Domestic/public Driven Gauge of Casing 44 ; <br /> Irrigation d Gravel Pack Depth of Grout Seal 4; <br /> Other Rotaryj <br /> Type of Grout i <br /> Other Other Information <br /> t L <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> � H.P. � <br /> PUMP REPLACEMENT: / / State Work Dane <br /> 3+ " <br /> PUMP REPAIR: / / State Words Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe. Material and Procedure Approximate Depth <br /> ti I <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 f <br /> after completion of. my work .ori 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 /> r <br /> SIGNED 1 <br /> TITLE 10 <br /> i ( RAW PLOT PLAN ON REVERSE SIDE t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTI N <br /> INSPECTION BY DATE INSFECTION BY DATE TSI <br /> CALL FOR A GROUT.INSPECTION..iPRIOR..TO GROUTING AND .FINAL. INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />