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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> Telephone: (209) 466-6781 <br /> jO <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 130. ��/� /-2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-!:�, -77 j <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 Joaquin <br /> th <br /> County Ordinance No. 1862 and the Rules a7} 'Regulations of theS�anoaq L �� ealistrict. <br /> JOB ADDRESS/LOCATION U�`� LV10 0, CENSUS TRACT _ -- <br /> Owner's Name 4I Phone K <br /> Address - — r City <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL /-T DEEPEN /7 RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> ik <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER lu�: <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> f 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 /> k PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F PUMP REPLACEMENT: / / State Work Done <br /> PUMP —/—/--State/.—State=Work-Donees <br /> ...rREPAIR--:,�.� �:-.� , :�...... .�.. <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia]. 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 /> TITLE <br /> SIGNED l 1 <br /> (DRAW P T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY `� <br /> PHASE I DATE 10--Z`�-7T <br /> APPLICATION ACCEPTED BY Z' <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION r DATE �- <br /> INSPECTION BY DATE INSPECTION BY <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 IM <br /> 4 E H 1426 <br />