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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No22_-Z1_2,V <br /> b_ U), h THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2_s'3 -- 2_1(o-(Z <br /> Application is he eby 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 Ordin nce No. 1862 and the Rules and Rg ula ions f thanaquin cal Health D' ic,�. <br /> i JOB ADDRESS/LOCATION -#j - CENSUS TRACT <br /> Owners Name _rtooPhone <br /> AddressCity <br /> t Contractor's NameLicense VZO-4-0— Phone <br /> f <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLAT N / / P PAIR / / PUMP REP LA NT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Doestic/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: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / State Work Done, <br /> ,DESTRUCTION 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 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 /> SIGNED A& 24TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPA§LNENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIX/FINAL INSPECT ON <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 3426 7/72 1M <br /> t <br />