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SAN JOAQUIWI CA17 'HEA,LTH DISTRICT <br /> FOR QFFICE SE: +1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� [J <br /> THIS PERMIT .EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1$62 and the R,ujes and Regulations of the San Joaquin Local Health District. <br /> ./, ST <br /> JOB ADDRESS/LOCATION Y CENSUS TRACT <br /> - <br /> Owner's Name �( <br /> �I�f � /ln �y , �/ /��?�/ - ----- - - Phone G <br /> � <br /> Address - 7�9� --. T� Likle_2 City i <br /> Contractor's Nam z2a �.L License # Phone S � <br /> - <br /> TYPE OF WORK (Check): NEW WELL /!;? DEEPEN /_f RECONDITION /__7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK Z;Z�ff SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �a <br /> Industrial Cable Tool Dia, of Well Excavation K <br /> v.--- Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal if <br /> - -_- <br /> Other Rotary Type of Grout <br /> Other Other I fo oration <br /> 0 <br /> y PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> a <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> -PUMP'REPi4IRa� <br /> ESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the.State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after '�ompletion 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 /> k <br /> SIGNED TITLE Q�Aj <br /> {D PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E -/" <br /> ADDITIONAL COMMENTS: j <br /> PHASE II RO STION P I NSPECTION <br /> INSPECTION BY DATR INSPECTION BY ATEA' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN 0� . <br /> E H 1426 7/72 1M <br />