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SAN JOAQUIN LOCAs, HEALTH DTSTRICT � <br /> F0117OFFfCE USE:, 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> O¢ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit­�No. ,7 <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d2' . i <br /> (Complete In Triplicate) <br /> ApplicatF,/niii\sereby 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 I <br /> County Ordinance No. 182 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO s 01 r— LF— CENSUS TRACT ' <br /> Owner's NameL UAl Phone ' 2Z. -- X770 —O/ 1 <br /> AJ <br /> Address zf -- l4/ I V S City <br /> 1 <br /> Contractor's Name co�_�� � License # Phone ' <br />-E TYPE,OFA-WORK (Check)-.- -NEW-WELL /DEEPEN'/ / RECONDITION /?. -DESTRUCT-ION�_/ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 �3 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKrf--SEWER DINES �-►- PIT PRIVY ------ <br /> SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ��Dndustrial Cable Tool Dia. of Well Excavation 9► <br /> omestic/praivate Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing E . <br /> Irrigation Gravel.Pack Depth of Grout Seal ?� <br /> Other, Rotary Type of Grout e_7 IE 0=— ~ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />'':DESTRUCTION'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 t- • L ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPAgTIXNT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS DATE 6r <br /> 19 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />