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FOR OFFICE USE• / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , 1601 E. Hazelton Ave. , Stockton <br /> Telephone: , Calif. <br /> P <br /> APPLICATION FOR WELL CONSTRUCTION6OR1PUMP PERMIT <br /> l permit No: 2�_�•SuJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ! l Date Issued a <br /> Application is hereby made to the San (Complete Triplicate <br /> Joaquin Local Health District for a <br /> and/or install the work herein described.. permit to construct <br /> County Ordinance No. 1862' aad the Rules and TRegulations tofnthe Sanis eJoaquinin pLocaleHealt with San tJoaquir <br /> ract. <br /> JOB ADDRESS/LOCATION Health District. <br /> CENSUS TRACT <br /> Owner's Name " .. <br /> Phone <br /> Address Y. <br /> City ci9..a <br /> Contractor's Name Z <br /> I <br /> Li <br /> cens? Phon;;� j-/;:�; 7 <br /> TYPE OF WORK (Check): NEW WELL / PEN /? RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION I� rUMP REPAIR :/—/ PUMP REPLACEMENT? <br /> Other /% /� <br /> DISTANCE TO NEAREST: SEPTIC' TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS A, <br /> e Tool Dia. of Well Excavation <br /> :tic/private z Drilled <br /> Domestic/public Dia. of Well Casing Y <br /> Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other "—,;:Z- <br /> -T—. Rotary � <br /> Type of Grout ol"o� <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP REPAIR: w <br /> / / State Work Done � <br /> ESTRUCTION OF ,WELL: Well Diameter � Y <br /> 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 <br /> TITLE <br /> (DRAW SLOT PLAN ON REVERSE SIDE <br />'RASE I F`OR DEPARTMENT USE ONLY <br />►PP IL CATION ACCEPTED BY 19 <br /> J)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTIO <br /> NSPECTION BYDATE PHASE III FINAL INSPECT N <br /> INSPECTION BY DATE + <br /> CALL FOR A GROUT INSPECTION�PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 I <br /> 7172 Im <br />