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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS FFICE. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued q=lq - -3 <br /> (Complete In Triplicate) <br /> Application is hereby 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. ,1862. and the Rules and Regulations of the San Joaquin Local Health Disfirict. y <br /> 00, <br /> JOB ADDRESS/LOCATION �^4_12A'] I �,t CENSUS TRACT <br /> Phone <br /> Owner's Name _ <br /> Address v Sb"[� , 7 u tl City <br /> License #,E /232" <br /> Phone <br /> Contractor's Name -- . <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN.'/ I RECONDITION I ./ DESTRUCTION <br /> ISTLLATItN / / PPUMP REPLACEMENT /� O <br /> Other <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LIKES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> industrial Cable Tool Dia. of Well Excavation• <br /> Domestic rivate Drilled Dia. of Well Casing <br /> Ip ! <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation - - Gravel Pack- Depth of Grout Seal GS <br /> Other 3 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s , <br /> PUMP REPLACEMENT: /y�/ - State Work Done <br /> PUMP TZEPAIR: { State Werk kDone <br /> j DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply faith all .laws and regulations of the San Joaquin Local Health District <br /> E and the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> s 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 kno e belief <br /> 1; SIGNED TITLE <br /> (D PL ON REVS SE SIDLE} <br /> FOR DEP USE ONLY <br /> PHASE I i j , DATE 9- <br /> APPLICATION ACCEPTED'BY <br /> ADDITIONAL. COMMENTS: t • <br /> PHASE II GROUT INSPECTION PHASE IT /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE rq� _ <br /> w CALL FOR-A GROUT.INSPECTION--PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />