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SAN JOAQUIN IOCAL HEALTH DISTRICT <br /> FOR OFFICEUSE: 01 E.. Hazeltoii Ave. , 'Stockton, Calif. <br /> Telephone: ,(209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S`L <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date Issued 2- Zdi <br /> (Complete In Triplicate) <br /> Application is :hereby�ma.de. 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 Rule's- and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address Cit <br /> _ 1 <br /> Contractor's Name _ C�1� ac,r —_- License �. 1 � Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN`/_/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR "/)(/ PUMP REPLACEMENT /7 ` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . <br /> < _ Domestic/private Drilled Dia. of Well Casing 1 . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �p <br /> Other Rotary Type of Grout ` <br /> Other Other Information ' <br /> „ ..rte <br /> PUMP INSTALLATION: Contractor . —0:d,l W �,,.�,, _ <br /> Type of Pump fe�L,,Io-_ ._ H.P. <br /> PUMP REPLACEMENT: / / State,-Work Done <br /> PUMP REPAIR: / State Work Done root?1 )/' <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 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 <br /> .information is true to the best''of my knowledge%and belief. <br /> SIGNEDC.�6_ '� - - r `d „TITLE <br /> A - fl - ( (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e' <br /> APPLICATION ACCEPTED -BY Vy '" .__ DATE. fo �•: <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS)V)XIjF1Xg INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _Z v <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE 0 . <br /> E H 1426 4/72. 1M <br />