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1/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y 1 8 tiJ <br /> i <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued` <br /> I (Complete In Triplicate) Z2(o - V?_0 ---,-,3 <br /> Application is hereby shade to the San Joaquin Local Health District for a permit to construct I <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 Loca_j He lth D trict. � <br /> JOB ADDREss/Lola . .. v : �� - <br /> o)f suS TRACT <br /> Owner's Name Phone <br /> Address q C �/Zl City , <br /> _Contractor's Name License #-_I& g;jt_Phcq e <br /> TYPE OF WORK (Check) : NEW WELL/T�'DEEPEN '/! RECONDITION 1 % DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other :/% --- <br /> DISTANCE TO NEAREST: SEPTIC ITATKQ SEWER LINES 7 - <br /> p` FIT FRiVY <br /> \L SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS lei <br /> IndustrialCable Tool' Dia. of Well Excavation A0, i` <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing 6149 <br /> Irrigation # Gravel Pack Depth of Grout seal <br /> Other �.._ s •. ,.._ <br /> _ Rotary Type of Grout .l3JEaf,&3 <br /> Other Other Information . _ t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . , <br /> _ u s <br /> PUMP REPLACEMENT: / /} State Work Done <br /> PUMP 'tEFAIR: State Work Done <br /> I <br /> .DF'ZTRUCTION -OF WELL: Well. Diameter <br /> Approximate Depth � <br /> Describe Material and Procedure <br /> � r <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 m kii wled a and belief. <br /> SIGNED <br /> �Z2t� stCZ6 L 21.J .�,, ,• <br /> TITLE <br /> (DRAW PL LA'. ON REVERSE SIDE) <br /> FQA DE .1ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPIf 5 Y DATE _Z- <br /> ADDITIONAL CO2MMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY / //-- �, �- DATE&1-1,3 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 r! /^70,.. <br />