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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 /> ZT APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedp_ <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 Distract. <br /> JOB ADDRESS/LOCATION / ,( eE CENSUS TRACT <br /> Owner's Name Phone <br /> Address lqAl <br /> City <br /> Contractor's Name ,,���� ,' i ' <br /> % �/�1L lS OcS. l�'/C.(�1�i�G Ld F ✓f;, License # 1j(� Phone <br /> TYPE OF WORK (Check): NEW WELL /�EEPEN / / RECONDITION /_-7, DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /7 <br /> Other /`/ <br /> DISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES PIT PRIVY <br /> xSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> _ Industrial iCable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. 'of Well Casing �y <br /> Domestic/public: Driven, Gauge of Casing ja C _ <br /> Irrigation Gravel Pack. Y Depth of Grout Seal <br /> Other / ? L-----Rotary Type of Grout <br /> 1` Other Other Information <br /> ;f <br /> PUMP INSTALLATION: ,., Contractor <br /> r` Type of Pump H.P. <br /> u <br /> C <br /> PUMP REPLACEMENT-� � / / State Work Done <br /> PUMP REPAIR: / / State Work Done �t T <br /> J ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> a <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 thebest of my knowledge and belief. Nd <br /> SIGNED TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE - �- <br /> -737 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ALVINAL INSPECT ON <br />' INSPECTION BYL&vDATE - INSPECTI DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND_. <br />'� ----E-H-=1426-__ _.�_� - - _-= - t--�-- - 7/72 1M y1� <br />