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fSAN JOAQUINiLCAV HEALTH DISTRICT <br /> FOR 2FFICE USE: f 1601 E. Hazelton �Ave., Stockton, Calif. <br /> i Telephone:' (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-- f 9 <br /> THIS PERMIT'EXPIRES '`1 YEAR FROM DATE ISSUED Date'e Issued <br /> f (Complete In Triplicate) <br /> ik Application is he ;ebyrnade to `the San-Joaquin Local Health District fog a permit to construct <br /> and/or install the work herein described. This application is made 'in- compliance with San Joaquir <br /> County Ordinance No... 1862` and the Rules and Regulations of. the San Joaquin Local Health' District. <br /> JOB ADDRESS/LOCATION CENSUS' TRACT <br /> Owner's Name 1. �. J K -, e,(� ,. ,...__. -- ---- Phone <br /> Address city „ . _ <br /> Contractor's Name License # 4,7 ,� Phone 4 941PS <br /> TYPE OF WORK (Check); NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_] <br /> PUMP INSTALLATION / / PUMP REPAIR �/ PUMP REPLACEMENT /? <br /> Other / /. <br /> t 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 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 /> PUMP REPAIR: / ./ State Work Done 0 <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 /> SIGNED r Vs. TITLE <br /> (DRAW PLOT P ON RVERSE SIDE <br /> FOR DEPARTMENT-USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEPTED BY /D DATE (� � "Z_2 z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING. AND FINAL INSPECT ON.- <br /> E H 1426 7/72 1M <br />