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SAN JOAQUIN LOCAL ITEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:-. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION--0R PUMP PERMIT Permit No. 7� 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2--J-LJZ-' <br /> (Complete In Triplicate) <br /> Application is hereby madef.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 /> County Ordinance No.,.;1862 and', the °Rule. and Regulations oche San oaquin Local Health District. <br /> CENSUS TRACT ' � <br /> JOB ADDRESS/LOCATION <br /> Owner.'s Name a Phone Y <br /> lI <br /> Address e7 0 {�} City k <br /> contractor's Name License # Phone <br /> k <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/�/ RECONDITION I I DESTRUCTION f { <br /> PUMP INSTLATION / PUMP REPAIRS&/ PUMP REPLACEMENT /? <br /> AL ? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ✓ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE_ SPOOQ SEEPAGE PIT OTHER <br /> INTENDED USE % TYPE OF WELL CONSTRUCTION SPECIFICATIONS J1 <br /> Industrial I,Cable Tool Dia. of Well Excavation <br /> Domestic/private, ,,„ ` Drilled Dia. of Well Casing � <br /> Driven Gauge of Casing <br /> -Domestic/public t5 <br /> Irrigation%� -i-=-Grave l Pack �i-it Depth-6f;.Groift,.S"I 5" <br /> i Other `+ Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> t H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> qj-,PUMP.REPAIR: /.-/.,. State Work Done X1.1_ .10 ' ! &t= <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 /> C 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 /> I information is true to <br /> the best of my knowledge and belief. <br /> SIGNED )'n• � 1 i[- TITLE <br /> (DRAW PLOT PLA ONREMSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `3 DATE <br /> APPLICATION ACCEPTED BY C ,. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> �. E H 1426 <br />