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ry .w 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. ;7,T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 7 and/or install the work herein described. This application is made in compliance with San Joaquil <br /> ' County. Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f 3�.o ". 141_6440rq-y <br /> JOB ADDRESS/LOCATION L so diA A r,. ENSU�TRACT <br /> .I x <br /> Owner's Name Phone <br /> Addressg �02�(� City C4"- G <br /> Contractor's Name C] XVW z11 r License #/tL 7 Phone 7,b <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /`7 - <br /> PUMP INSTALLATION / / PUMP REPAIR Y/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TK <br /> ANSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> x 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 x <br /> yC . Irrigation Gravel Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of Pump u. w h '4' H.P. <br /> PUMP REPLACEMENT: �, .. _ ....,...,._� <br /> State Work Done <br /> PUMP REPAIR. j State Work Done , <br /> ,DESTRUCTION OF WELL: Well Diameter w. 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 /> S I GNE A <br /> r as TITLE <br /> Afib&RAW4SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> . , <br /> ADDITIONAL COMMENTS= <br /> PHASE II GROUT INSPECTION PHAS II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 A 7/72 1M. <br />