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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .OF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209);466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. hJ <br /> Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3./u. 7�y <br /> wis (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 /> G County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health Disgrict. <br /> r <br /> JOB ADDRESS/LOCATION JQ CENSUS ,T�/RACT ' <br /> Owners Namex / A- <br /> r <br /> �� 7 <br /> Address City ,f..', <br /> 5 <br /> Contractor's Name �,,,_ �1�b A_J!� - License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / tRECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PU" IP REPAIR I / PUMP REPLACEMENT I�T <br /> Other I / _.,: . . <br /> DISTANCE TO NEAREST: SEPTIC TANK .7-5 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER O <br /> } <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,��Ihdustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> - --- Domestic%public Driven a Gauge of Casing <br /> Irrigation Gravel-Pack. ``, `Depth`of Grout Seal <br /> Other - Rotary . Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor- -v - _ - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done , <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth S�3' <br /> _ I Describe Mat ial and Procedure <br /> � <br /> �e <br /> I�hcreby agree to com ith all aws and re ulations of the an oaq n o al ea t-H District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my olik 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 's tru the bes of my.knowledge and belief. <br /> ;z SIGNED TITLE <br /> (D LOT PLAN ON ,REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 8Y DA 3 <br /> ADDITIONAL COMMENTS: I <br /> 4 PHASE II GyAgj IAPECTI#V PHA I INSPECTION <br /> tt/ <br /> € INSPECTION BY ATE v INSPECTION. BY DATE <br /> CALL FOR A GROUT-INSPECTION PRIOR_TO'GROUT.ING 'AND-FINAL..INS N. <br /> F. H 1426 5/731M <br />