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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . OISE 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedg-, <br /> (Complete In Triplicate) l 4/— Z5-0-02__ <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 Sart Joaquin <br /> County Ordinan o 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION J ,r � CENSUS TRACT <br /> Owner's Name'% Phone-If/16 6' </011f' <br /> Address City <br /> Contractor's Name lae. . � � 3 7 <br /> License 9���,.2� )�, Phone'`j``� <br /> TYPE OF WORK (Check) : NEW WELL J J DEEPEN / / RECONDITION DESTRUCTION _ <br /> AL -/ � <br /> PUMP INSTLATION PUMP REPAIR �_PUMP REPLACEMENT /_7 <br /> Other /_7 O <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 /> 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 INSTALLATION: Contractor <br /> Type of Pump � � -�-,; H.P. ��— <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP UPAIR: State Work Done <br /> 01 <br /> ,DFCTRUCTION 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 a <br /> WELL DRILLERS REPORT of the well and notify thew before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ��/� .�- � TITLE <br /> ) (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6� DATE o2e�. <br /> ADDITIONAL COIMNTS: <br /> PHASE II UT INSPECTION PHA5E I INAL INSPF,9. N <br /> INSPECTION BY OUA DATE INSPECTION BY DAT <br /> 1 .000- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />