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l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !FOR FICt USE: 1601 , <br /> T . l�.azelton Ave. , Stockton, Cal-if. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUME PERMIT Permit No, 3 . al� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> r <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> . nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> FCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOC ON kn 0 /a <br /> CENSUS TRACT <br /> saner f s Name _ Phone <br /> Address <br /> City { <br /> F.ontractor? Name "'"""" — <br /> `. License # 1 —Phone Z <br /> PPE OF WORK (Check) : NEW WELL % ; DEEPEN 1 I RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR Zy PUMP REPLACEMENT <br /> Other <br /> JSTANCE TO NEAREST: SEPTIC TAN' _ -. _ SEWER LINES .PIT PkIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � � Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ; <br /> F. Other Other Information <br /> -- <br /> UMP INSTALLATION., Contractor <br /> Type of Pump ._.�. `�- •"` r�� y H.P. <br /> PUMP REPLACEMENT: / J State Work Dene <br /> UMP REPAIR: <br /> 6C/ State Work Done . <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure } <br /> � hereby agree to comply with all laws and regulations of the San Joaquin Locai Health District <br /> nd the State of California pertaining to or regulating well. construction. Within FIFTEEN DAYS <br /> Rafter 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 /> czformation is true to the bes�tyof ,ipy knowledge and belief. <br /> SIGNS a �` .+ v", S TITLE <br /> i <br /> ,(DRAW `PLOT PLAN ON REVERSE SLDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AFPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: N <br /> PHASE II GROUT INSPECTION PRASFy4IIjFINAL INSPECTI <br /> DAN <br /> INSPECTION BY BATE INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />