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Q/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OVFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 3-L(-(_7 cJ <br /> „APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued`k=5^� 3 <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I' -7 CENSUS TRACT S L <br /> i Owner's Name Phone 'u 6 4 - a 0 tf 3 <br /> Address 31' ;z "r le City S 7/'A/ <br /> Contractor's Name /�� V .r License Phone <br /> TYPE OF WORK (Check) : NEW WELL,/Z DEEPEN / / RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / -V <br /> . <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 . SEWER LINES PIT. PRIVY \ <br /> SEWAGE DISPOSAL,FIELD CESSPOOL/SEEPAGE PIT OTHER \1 <br /> 1 S_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �{ <br /> E _ Industrial 4 Cable Tool Dia. of Well Excavation /a,, <br /> Domestic/private Drilled Dia. of Well Casing � <br /> /P �' Gauge of Casing <br /> Domestic/public Driven" + <br /> Irrigation Gravel Pack Depth of Grout Seal D <br /> Other Rotary Type of Grout — <br /> Other Other Information.,/ 9,� � - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , <br /> �l � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR, / / State Work Done',,% • -. -. - <br /> ESTRUCTION 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 furnigh the Saar 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 /> k <br /> SIGNED LE �- <br /> (DRAW PLOT PLANKYN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ^? <br /> ADDITIONAL COMMENTS: <br /> " Y'PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY, di DATE - �_ _ . INSPECTION 'BY 4DATE &-,f2 -/. <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />