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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ©� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �//� <br /> PL CATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. C�u ble . <br /> HIS PERMIT. EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued / �2 7 y <br /> (Complete In Triplicate) <br /> Application is hereby de .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. 1862 and the Rules and Regulations f the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION ��/ KV a -G' ('"o.L 7,p CENSUS TRACT <br /> Owner!s Name _ It ' &0:5,: Phone ' _ — 0 <br /> r� 1?J <br /> Address 3a��a7 �_ � , -- � -- � city O...... N <br /> r n License # Phone ' <br /> Contractor's Nameej ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION If I PUMP REPAIR / I PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY b <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 f H.P. i <br /> I <br /> PUMP REPLACEMENT: / / State 'Work Done n:an' j:�a IL) <br /> .PUMP-REPAIR; /� tate Work Done <br /> .DESTRUCTION OF WELL: Well Diameter '" s.� 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 /> and belief.a <br /> information is true to the best o my knowledge y <br /> 4 <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR "ARTXATI E ONLY <br /> PHASE I DATE <br /> APPLICATION ACCE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P, S I INAL INSPECT N r� <br /> INSPECTION BYDATE INSPECTION BY ; DATE LD !r <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> H 142b 4/72 1M <br /> C63 <br />