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SAN JOAQUIN LOCAL HEALTR DISTRICT <br /> FOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :z `5 7 6 <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 17 j y <br /> (Complete In Triplicate) <br /> Application .is hereb 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. 1.862 and .th�j-_Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION W w.1 jgVAL.1at CENSUS TRACT <br /> Owners Name 6 Phone <br /> Address q-3 9S A/ City jy-0 c.,��j <br /> Contractor's Name License <br /> # j---Phone V4-A--79 7&' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> 1 PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> 1 <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 ..(` . 4,16 H.P. / T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done r,m rAt 42r, - <br /> 4 %1 <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 well in use?The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE [J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO9 PHAS AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --- - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE <br /> E H 1426 4/72 1M <br />