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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �F0F. OI1IC1 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�- 99 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION MyI3CENSUS TRACT S'SrU <br /> Owner's Name J Phone <br /> Addressa City <br /> Contractor's Name License # Phoney <br /> 0 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPQSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE f TYPE OF WELL CONSTRUCTION SPECIFI/CATIONS <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 AA d226A_Z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLCEMENT: / / State Work Done <br /> �� rt <br /> PUMP UPAIR: / / State Work Done <br /> DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 Sar: Joaquin Local Health District a 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DE TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED.. ATE �l <br /> ADDITIONAL COMMENTS: k <br /> P I GROUT INSPECTION P I/ AL INSPECTION <br /> INSPECTION BY 7 DATE �- - INSPECT Y DATE �� <br /> CALL FOR A GROUT INSPECTION PRIOR TO G OUTING AND FINAL INSPECTION. <br /> F.H 1426 - -- /71 im <br />