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SAN JOAQT3rN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 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 Issued ,2 ��--7� <br /> (Complete In 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....1$62 and the Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Motel ❑Other -------------------------------------------- <br /> Contractor's Name License Phone 1119 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/� RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / i, <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 U <br /> Industrial CableTool Dia. of Well Excavation ,, <br /> Domestic/private _ Drilled Dia. of Well Casing 41f: <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 /> p <br /> 4 <br /> PUMP .INSTALLATION: Contractor � � s <br /> Type of Pump 0 H.P. i <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 0 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 i <br /> information-is true to the best "of my knowledge and belief. <br /> SIGNED 1. Q �� TITLE <br /> .- / . . (DRAW PLOT PLAN ON <br /> REVERSE SIB <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'ACCEPTED BY DATE -- <br /> ADDITIONAL COMMENTS:,•:.'-. <br /> PHASE JI. GROUT INSPECTION " PHAS I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2i <br /> CALL FOR A• GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECT " . � <br /> E H 1426 rx 4/72 1MF ° <br />