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' = SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF-O FICE 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 <br /> In Triplicate) <br /> t 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. 1862 and the Rules and Regulations of the San Joaquin. Local lleal.th District. <br /> JOB ADDRESS/LOCATION / <br /> P e F s ' oj CENSUS TRACT ZZ�- <br /> Owner's Name Phone ' <br /> i <br /> k <br /> Address City <br /> i <br /> Contractor's Na License # ,5-VZPhone <br /> i � <br /> TYPE OF WORK (Check) . NEW WELLAALTION <br /> DEEPIN '/ / RECONDITION /_/ DESTRUCTION /-7PUMP INS / / PUMP REPAIR / / PUMP REPLACEMENT 1-7 <br /> k Other <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PIT PRIVY fT1 <br /> SEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT .OTHER <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS m <br /> Industrial Cable Tool Dia.. of Well Excavation 1n <br /> a,"YDomestic/private t/ Drilled Dia. of Well Casing <br /> — - - <br /> _ = _ <br /> ""�'-"Do�esti.c/public �--"�"-` -� - Driven- `�' Gauge�of- Casing ,i,--' Irrigation --;:;:7-Gravel Pack Depth of Grout Seal <br /> Other f/ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP:REPLACEMENT: / / State Work Done <br /> 3t PUMP 'tEPAIR-Y Y �/ % = State Work Done <br /> DF TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> e I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Califo3rni.a! 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 /> ' 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> j information is true to the best of my knowledge and belief. <br /> SIGNED - TITLE <br /> s I (DBAMPLOT PLAN ON/REVERSE SID <br /> i OR ARTI+�`NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE <br /> ADDITIONAL COMMENTS: l-' <br /> PF I T SP C 10 PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. /-2e <br /> E H 1426 76 1� - �� �'S/7 <br />