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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION w)W�1'i,"o a e A4,to C& j A,.-,,I, CENSUS TRACT <br /> Owner's Name , n Ccs Phone <br /> J) ma�yy <br /> Address o/� ; City _dlow. <br /> Contractor's Name / License #Off 'Phone ��t` <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /_� RECONDITION /-7 DESTRUCTION /-7AL <br /> PUMP INSTALLATION /—/ —PUMP PUMP REPAIR Y/ PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY v.A <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> PUMP INSTALLATION: Contractor � w <br /> Type of Pump 'T?.cr: eh� - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done 4-d4 ('d/tc n ,h 4 e ":/l <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 /> information is true to the best of my knowledg �tf .ief. <br /> SIGNED $ ITLE <br /> (DRA PIT PLAN ON RE RSE ID-ET— <br /> V MR <br /> DEPARTMENT USE ONLY <br /> PHASE I � 7 <br /> APPLICATION ACCEPTED BY -'" DATE L. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />