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�F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7C,5_77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - - <br /> (Complete In Triplicate) <br /> Application is hereby rade 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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� ! CENSUS TRACT <br /> _. <br /> Owner°s Name �i°Y.• -- Phone <br /> Address City <br /> Cant'actor's Name a_.;�? License #,2f V?8f'Phone J 2 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION f_1 DESTRUCTION _f_7 <br /> PUMP INST LLATION =4 PUP REPAIR/ / PUMP REPLACEMENT /� <br /> Other / / — — O, <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool" Dia. of Well Excavation jj 'y �- <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ n <br /> -- -- -- - <br /> Irrigation. Gravel Pack Depth of Grout Seal 6 t" <br /> Other Rotary Type of Grout <br /> Other Other Information^ <br /> PUMP INSTALLAATION: Contractor <br /> =TYpe of"Pump � <br /> PUMP REPLACEMENT: / f State Work Done <br /> PUMP U-PAIR: / J State Work Done <br /> DF-TRUCTION OF-'WELL: Well Diameter - --fa-�� Approximate Depth <br /> Material and Procedure <br /> D05Crlb��� M3 r� -- i <br /> I hereby agree to comply wiK all laws .and regulations of the San Joaquin Local Health District <br />} and the State. of California pertaining to'-or regulating weil ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wellp.:.I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of .the well and notif <br /> y. .them before putting the well, in use. The above <br />,i information is true to the best of my knowledge.and belief. <br /> t SIGNED TITLE <br /> (DRAW=PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATEz et- <br /> -7-ADDITIONAL, COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> - <br /> INSPECTION"BY -- _..DATE rt: , - _ ,,.INSPECTION .BY f.� DATE_. <br /> � ��-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. I <br /> L- T3 ,,.I)4 C�l /7Z <br />