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FOR OFFICE USE: ;e-AN JOAQUIN LOCAL HEALTH DISTRICT.__ <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PET0 o 3 <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED Date Issued <br /> (complete Triplicate) <br /> Application 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 Joaquin <br /> County Ordinance No. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q 8;1d_-Z <br /> x� CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City c <br /> Contractor's Name License # Phone <br /> - _ I <br /> TYPE OF WORK (Check): NEW WELL /-" DEEPEN / / RECONDITION /7 DESTRUCTION J <br /> PUMP INSTALLATION _/ / PUMP REPAIR / / PUMP REPLACEMEN -7 <br /> Other /. / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER I <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 /> Other Other Information <br /> PUMP INSTALLATIONS Contractor � I <br /> Type of Pump i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /_7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter �f Approximate Depth ,L��-- <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 II&AI& TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS5 IIIIFINALINSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M a - <br />