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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFn�ion <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> '. �HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> g (Complete In Triplicate) <br /> Applicaade 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION GLlG,�� ��i✓m e?,� , CENSUS TRACT <br /> f Owner's Name � � G`C�'�t `�� Q. 4e Phone <br /> Address �(�. <br /> Contractor's Na _ �` `� License #/_I Cw Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /" / PUMP REPAIR'&/ PUMP REPLACEMENT /_ <br /> Other /_7 <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 7� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary , Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor, CS <br /> Type of Pump "� ._ H.P. / <br /> PUMP REPLACEMENT:' / / State Work Done <br /> PUMP REPAIR: State Work Done �_-- -- - <br /> ,PESTRUCTION 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 pe.rtai.ning 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 be of knowledge and belief. <br /> r <br /> 2" X <br /> STGNE TITLE F <br /> �,. <br /> (DRAW PLOT PLAN VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - e <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GR IN5 ZOTIQ PHAS III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 _ 7/72 1M <br />