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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,,• Stockton, Calif. + <br /> Telephone: `(209) ..466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,)•-3 ` <br /> T c(7 v 3 i <br /> THIS. PERMIT EXPIRES 1-YEAR.'FROM DATE ISSUED Date Issued <br /> (Complete In,Triplicate) - 05!3 _pzd <br /> 3 <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.-,.l862 .and .the, Rules and Regulations of the Sar► Joaquin Local Health District. <br /> San <br /> JOB ADDRESS/LOCATION /{f �3 a5 ,7 � .�.c. CENSUS TRACT ' S y 7 <br /> Owner r s ;`Name [ I I . .=a n Phone- _ <br />;.,:Address City <br /> Contractor s Name /��,� +�i- . • V. License # Phone <br /> 'TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION A/ PUMP REPAIR -/ / PUMP REPLACEMENT /_7 W <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY ^J <br /> SEWAGE DISPOSAL FIELD SLVIt 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 a <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor it ,•yy <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 lawns 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 ue to tapest of my knowledge and belief. <br /> SIGNE<z <br /> TITLE <br /> � (DRAW PLOT PLAN ON REVRRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� ��� _ DATE <br /> .ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE74 <br /> CALL �OR A, GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />