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JOAQUIN LOCAL HEALTH DISTRIG J . <br /> FOR OFFICE USE: /1664. Hazelton Ave. , Stockton, Calf <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Xpplication 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 Joaqui- <br /> �ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION ✓'..� f• CENSUS TRACT <br /> Owner's Name ' <br /> address <br /> � °' "�► '�` City <br /> r� A . <br /> Contractor's Name,--<Z",1- License #/22SS6i Phon <br /> - r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INS ALLATION / / PUMP ,P�AIR / ] PUMP REPLACE NT <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> c <br /> Industrial Cable Tool Dia. of Well Excavation R <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 /> Other Other Information <br /> PUMP INSTALLATION: Contractor p <br /> Type of Pump H.P. �l <br /> 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 F <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 .,' ' -:�� o <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7,.._Z 7 <br /> APPLICATION ACCEPTED BY DATE9-::_ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FI AL INSPEC ON <br /> INSPECTION BY DATE INSPECTION BY TE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ?/72 1M <br />