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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOUR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> rA Telephone: (209) 466'=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ja- __2D e <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f 6A. v- CENSUS TRACT <br /> Owner°s Name A" d to r rt, '0/ Y J L 0 -Z::�) Phone <br /> f <br /> Address (a" !J ,-C�..c.-_ 'T'o»e City w 1A71cz_;?\ <br /> Contractor's Name License # 1,?3 7,--.s Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�% RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT /- <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 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing O <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graved Pack Depth of Grout" Seal (� <br /> Other Rotary -, Type,of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ut A, r H.P. . <br /> t State Work Done rr^ ..,. err� 01� <br /> PUMP REPLACEMENT: / / �i0 ..� sir-,. , <br /> v <br /> PUMP REPAIR: / / State Work Done <br /> y,.PESTRUCTION 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 knowledge and belief. <br /> SIGNED O TITLE <br /> Y <br /> �bRAW'PLOT PLAN`ON"REVERSE SIDE�r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ; APPLICATION ACCEPTED BY DATE or �� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INSPECTION <br /> INSPECTION BY / DATE _______� INSPECTION BY DATE <br /> CALL FOR A"GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS P 0 . 7 <br /> E H 1426 7/72 1M <br />