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SAN JOAQUIN-LOCAL HEALTH -DISTRICT <br /> 1�0}.:OFF.ICE USE: 1.601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1'3-_4 I& U <br /> F _ ... <br /> f THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued �'-cq_7 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 Joaquin <br /> County Ordinance No. 1.$62 .and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION OQ l CENSUS TRACT <br /> E Owner's Name l 'Do 7l. 4*-e - - -- Phone <br /> ! Address & City <br /> -44 <br /> Contractor's Name �Nt/ � <br /> ' License # ,/ Phone -76 <br /> F TYPE OF WORK (Check) : NEW WELL'./ / DEEPEN -/-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE{3F 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 cif ,Grout .. <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / State-Work Done (, IV- e,4-"i _ems <br /> .DF-,TRUCTION OF WELL: ,.Well Di�adiieter 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 knowle and el,ief. <br /> ! SIGNED f TLE <br /> (D P OT LAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED .BY �� TE --� <br /> ADDITIONAL COUNTS: <br /> PRASE II GROUT INSPECTION PHA AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 'DATE <br /> r. CALL-k'OR-A-GROUT-.INSPECTION- PRIOR-.TO-GROUTING AND FINAL INSC N. „ w <br /> V N ,l,?A 5/731M <br />