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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-F,6-r­0-FF1C-E- 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 )_I- <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 R les and Reyula#qns of the San Joaquin Local Health District."\ <br /> L 04, <br /> 1�� 00ST <br /> X <br /> JOB ADDRES I <br /> � 1 A TO -,,3ADQ-- CENSUS TRACT <br /> ' <br /> r'-A Name >> Phone <br /> e4 <br /> Addr ss City <br /> Contractor's Name License 71V Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN/_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/—pump REPLACEMENT— /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL YIELD CESSPOOLfSEEPAGE-PIT'--- OTHER <br /> 6(_ 4- <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: State Work Done <br /> ?FqTRUCTION-OF WELL: Well Diameter /4 Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health D stric <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informati is rue to the best of my4nowledge and belief. <br /> SIGNED TITLE 1, ,"zx- <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PdASE Iz-X-,o - <br /> APPLICATION ACCEPTED BY CDATE '015-6 <br /> ADDITIONAL COMMENTS: V2A, <br /> .i57ZitVa <br /> PHASE II GROUT INSRECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY e'-Al DATE .9 5/6Z 10 171� A <br /> INSPECTION BY If jo DATE 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />