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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 No. ZLZLe-e i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' � ' <br /> (Complete In Triplicate) <br /> Application is hereby made to .the Joaquin Local Health District for a permit to construct <br /> and/or install .the work herein described. This aptionstofnthe is SaneJoa ui in pLocaleHealthwith SDistrictan ln <br /> County Ordinance. No_. 1862 and rthe .R a :and Regula u � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> PhonName <br /> Owner's <br /> E � s <br /> Q o � � - city <br /> Address .� <br /> License #` Phone <br /> Contractor's Name Y <br /> STRUCTION <br /> TYPE OF WORK (Check) : NEW WELL I 1 DEEPEN "/_I I.RECONDITION I p1tMPER&PLACEMENT/7 <br /> PUMP INSTALLATION / PUMP REPAIR'/ <br /> / y, <br /> Other <br /> DISTANCE TO NEAREST: SEPT C TANK~ WER LINE r PIT,PRIVX <br /> SEWAGE DISPOSAL7FIELD CESSP OL/SEEPAGE PIT OTHER <br /> INTENDED. USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4 , <br /> Drilled Dia. of Well Casing--. ws <br /> Domestic/private }« <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, . <br /> Other Rotary Type of Grout <br /> 4 <br /> Other Other Information ' <br /> 1 <br /> PUMP INSTALLATION: "" Y Contractor <br /> Type of Pump H.P. <br /> PU�T REPLACEMENT: State Work Done c <br /> -. <br /> PUMP REPAIR; / / State Work Dane _ <br /> Approximate Depth <br /> DESTRUCTION OF.WELL: Well^Diameter <br /> �( <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 i true to the est of my knowledge and belief. <br /> TITLE <br /> T <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> E PHASE 'II GROUT INSPECTION INSPECTION BY /� DATE 3-C 7_� --- -- <br /> INSPECTION BY DATE r - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M � <br /> E H 1426 <br /> F <br /> f <br />