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FOR OFFICE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 l YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is In hereby made to the San (Joaquin eLocal Health District for a <br /> permit <br /> and/or install the work herein described. This application is made in compliancetwithnSan uJoaquin <br /> County Ordinance N 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRIE s6 3 3 <br /> /LOCATION �° � � JI � <br /> Owner's Name <br /> CENSUS TRACT <br /> - <br /> Phone <br /> Address 42 City <br /> Contractor's Name 4 f <br /> �. License Ardy Z �Phone c <br /> �--- <br /> TYPE OF-WORK- (Check) : -NEW WELL / DEEPEN _ f <br /> RECONDITION I� DESTRUCTION /� <br /> PUMP INSTALLATION �/ PUMP REPAIR / / PUMP REPLACEMENT /� T <br /> Other / / — 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER � <br /> INTENDED USE TYPE OF WELL W <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> !/Cable Tool Dia. of Well Excavation 0 <br /> =omestic/private Drilled Dia. of Well Casing b <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -- <br /> Other Gravel Pefck Depth of Grout Seal p <br /> _ Rotary Type, of Grout <br /> Other ._ Other Information <br /> PUMP INSTALLATION: Contractor dlle�J <br /> Type of Pump <br /> H.P. <br /> PLUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR, State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 Q.v <br /> ].-TITLE ( jLP�1 <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> WDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE _ Z 14 <br /> - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />