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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR' O'FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f5142iJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E__,Ly 7J <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 ,E` ( CENSUS TRACT <br /> Owner's Name Phone 3� � J <br /> Address ( a <br /> Izz City -�-r <br /> Contractor's Name icense -� Phon <br /> � <br /> TYPE OF WORK _(Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / T UMP P IR REPLACE NT /7 <br />. � 0th <br /> T" <br /> DIS CE 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal qqq <br /> Y .. Other :; Rotary TYpewof'Grout- zz- <br /> Other Other Information <br /> PUMP INSTALLATION Contractor <br /> Type lfof Pump H.P. <br /> PUMP REPLACEMENT: / / :�State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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, 1 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 SI E <br /> FW DEPARTMENT USE ONLY <br />' PHASE I _ <br /> APPLICATION ACCEPTED BY DATE �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '=7 <br /> :I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 p, 7/72 1M <br />'i »......f,_.. :...n. ,:�c. ":,a«;� 1 Y`ti. is c, vx„ .u• rs-,��c iiei9's�,A.:x ?'c�-- ' - o �.•.a!'- .� r5. fi �.- - xx+r w. <br />