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SAN JOAQUIN 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. 72 - <br /> THIS <br /> -THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 7 <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 <br /> 4 � CENSUS TRACT <br /> Owner.'s Name � �—�,�,,� . Phone ' <br /> (17 <br /> Address City. <br /> Contractor's Name License Phone " <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN /7Z RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION I I PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other: / / <br /> i� <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> t <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool f Dia. of Well Excavation t .� <br /> Domestic/private Drilled Dia, of Well Casing W <br /> Domestic/public Driven Gauge of Casing {� <br /> Irrigation r. Gravel Pack Depth of Grout Seal t <br /> Other Rotary Type of Grout j <br /> Other Other Information rZ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: State Work Done .>* , <br /> PUMP REPAIR: J 14 <br /> State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> -- 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 <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 DEPARTMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY a .G , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �. PHASE II/FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. i <br /> E H 1426 4/72 IM <br /> x <br />