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'WCC 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 7CtJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 /S-)6 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT 2-04- 690-07 <br /> Owner's 'Name / Phone/?, f <br /> Address / /� OTr <br /> - City <br /> Contractor's Name G 'L License X 59 Phone44�.2-/9�2 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/!.f PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t� <br /> O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> P/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /13— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 1 —Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e. f H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REP A / / State Work Done <br /> ESTRUCTION OF WEL Well Diameter Approximate Depth 5 � <br /> Describe Material and Procedure ` <br /> I hereby agree to comply with all laws and regfulations 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 he best of my knowledge and belief. <br /> SIGNED _ TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPART ANT USE ONLY <br /> PHASE I "A1i�L. <br /> APPLICATION ACCEPTE DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO1UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYD E 8 �- <br /> CALL FOR A GROUT INSPECT ON PRIOR TO GROUTING AND FINAL INSPE IO . <br /> E H 1426 4/72 1M <br />