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r 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. _� d <br /> 7Z4`�'-. <br /> Qfg� THIS PERMIT EXPIRES 1'YEAR FROM•DATE:-ISSUED -.Date Issued <br /> ('Complete �In Triplicate) <br /> Application•;,is-ahereby;;made..to ;the)San.,Joaquin-Local Health •Distriet1for -a permit••to tconstruct <br /> and/or install the work herein described. Thib-.applicat:Lon,,is`•made_in.compliance with SaniJbaquin, <br /> County,Ordinance-No:V~,1"86 .and,;the-=>Rules-,and Regula tions:'of,�-the. Sane Joaquin:Local--Health District. <br /> JOB ADDRESS/LOCATION <br /> -tr '.1. r --C ? i' '.`- .�.'.T ,, r.,.• t... CENSUrS:•TRA_ C.T`~ <br /> q;J ,S` :9.. <br /> 3.)Owner's: Nam: e <br /> " <br /> t i; •,. v. =Phone <br /> Address <br /> City, <br /> Contractor's Name <br /> � License Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN I I RECONDITION /�/ DESTRUCTION /-7 <br /> PUMP INSTALLATION'/ / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other - <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK Z)Q SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> s <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Industrial _.At::t Cable Tool Dia. " <br /> of Well Excavation . / <br /> Domestic/private Drilled Dia, of W <br /> . - Well Casing ZY <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 i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: / / State Work Done <br /> REPAIR: <br /> PUMP <br /> .� /—/ State Work Done - <br /> - <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby ag a to comply with all laws and regulations of the San Joaquin Local Health District . 4 <br /> and.the Sta a of California pertaining to or regulating well construction. Within FIFTEEN DAYS` <br /> after completion of my work bn 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 /> SIGNEDd � r~ <br /> ' TITLE•_� <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $Y DATE -�- <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASIII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY44gDATE /d-1,A.. <br /> ,,;,CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 __ .. - 4/72 1M , <br />