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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR USE: 1601 E. 'Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3--'4S L,,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued tj 3 <br /> i (Complete In Triplicate) I F <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health 'District. <br /> 1.��� ill ..r� .S7j:J".,��J''; <br /> y �/ Q ��� osD--c1 <br /> JOB ADDRESS/LOCATION V CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address - - City <br /> Contractor's Name License 41,4 Phong �3 / <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTAL TION / / 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Iiia, of Well Excavation <br />_ omestic/pr ivate ___,L.1 Drilled Dia. of Well Casing k' <br /> Domestic/public Driven Gauge of Casing 40 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout 474C4d __ 4 <br /> Other Other Information r <br /> d <br /> PUMP INSTALLATION: Contractor e <br /> Type of Pump H.P, <br /> E <br /> PUMP REPLACEMENT: / / State Work Done . <br /> t <br /> 4 <br /> PUMP REPAIR: /% State Work Done , <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> - _ <br /> Describe Material and Procedure <br /> y <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 my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> --- FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> �P3AEa GROUT INSPECTION PHASE III FINAL INSPECTION IUC <br /> INSPECTION BY j jai, .Vf DATE .. INSPECTION BY , DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />