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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: I 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?r¢-30 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7-t- <br /> (Complete In Triplicate) <br /> Application is hereby made tothe 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 v-Q- 1 CENSUS TRACT <br /> Owner's Name J Phone 7 � Z� <br /> Address {". City . <br /> Contractors Name A ' License # Phone <br /> r ! . <br /> TYPE OF ,WORK (Check.) : NEW WE L:- / / .M DEEPEN / J RECONDITION /_-7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /, / + — <br /> i <br /> DISTANCE TO.,.NEAREST: •SEPTIC TANK SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/5 EPAGE PIT OTHER <br /> NTENDED USfE TYPE ELL CO STRU TION SPECIFICATIONS <br /> Industrial i` Cable Tool Dia, of Well Excavation <br /> Domestic/private k.Drilled Dia. of Well Casing <br /> Domestic/public , -Driven , Gauge of Casing <br /> Irrigation -�. t, •i Gravel Pack D6pth of Grout Seal <br /> Other ' <br /> - -,1 __ _ Rotary . ---Type. of _Grout_ ..._ r •.# s <br /> a _ 1 Other Other Information M _ <br /> { <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type ofIPump 17 H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: / / State Work Done <br />,PES-TRUCTION .OF .W.E._LL_: Well Diameter promawDep b <br /> DescribMate, Procedure <br /> , <br /> I hereby agree to comply with all laws and regulations of the 'San Joaqu Local Health District <br /> and the State of California pertaining to or regulating well constructio . 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 rue to the best of my knowledge and belief. j <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ �2�a�[.r" _ DATE <br /> ADDITIONAL COMMENTS: � <br /> PHASE II GROUT INSPECTION PHA 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 7/72 1M <br />