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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 L5 <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued 2,� <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 /> Count Ordinance. No..w1862_ and .the Rules nd. Re uI tions of the San Joaquin Local Health District. <br /> K,4•r,�o,4 � a �S l-tWc f. (jC1_ A.,-4n) 0�tfS <br /> JOB ADDRESS/LOCATION . CENSUS TRACT ! <br /> Owner's Namenm 13�_Ku Phone <br /> Address . » Li�lt. x- City t, <br /> Contractor's Name License #2joj Phone <br /> TYPE OF WORK (Check) : NEW WELLI / DEEPEN RECONDITION /_/ DESTRUCTION /7 <br /> Ig_ <br /> PUMP INSTALLATION PUMP REPAIR '/—/ FUMP REPLACEMENT J cad <br /> Other /�/ on <br /> DISTANCE TO NEAREST: SEPTIC TANK 21 SEWER LINES PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -y- OTHER <br /> - <br /> 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information %A <br /> PUMP INSTALLATION: Contractor _ !� 12 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 /> 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 /> informatio s a),aA <br /> true he est of my knowledge and belief. <br /> SIGNEDTITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE2,02� �- <br /> ADDITIONAL COMMENTS: <br /> PHASE I.T GRdUTf9SPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a5z 2aDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM C�" <br />