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C/ f/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOi.ZHICE UM; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> L __.. Telephone.: (209) 466-6781 <br /> APPLICATION EOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �r __ � <br /> -THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 2 -O-74- <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 Jaaquini <br /> County Ordinance .No. 1862 a d the Rules and Regulations of the San Joa%uin Local. health Dis�ri:ct. <br /> �iy0-01 <br /> JOB ADDRESS/LOCATION y T CENSUS TRACT . <br /> Owner's Name Phone 1 6_14 <br /> Address <br /> Contractor'..s Name License # 14Wz r Phone J <br /> { <br /> i <br /> TYPE OF WORK (Check) : NEW WELL �/ DEEPEN '/E/ RECONDITION /—/ DESTRUCTION I? � + <br /> PUMP INSTALLATION I I PUMP REPAIR '/ / PUMP REPLACEMENT /_7 <br /> Other../ / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1�1 ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation i Gravel. Pack Depth of Grout Seal <br /> Other q Rotary Type of Grout <br /> h <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />" T UMP 'ZEPAIR: / / State Work Done <br /> k <br /> DRRTRUCTION 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 /> alter 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 /> SIGNED,.- TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED -BY 5DATE,4 <br /> 12 <br /> ADDITIONAL CO',OMNTS: + <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ R": 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 mop C�/711 <br />