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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFF ICE USL: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> Telephone: , -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L/- ,23 S-U/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued :$r'7�L <br /> (Complete In Triplicate) C)6 - bid a/ <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 o€ the San Joaquin Local Beal-th District, <br /> JOB ADDRESS/LOCATIO �: 3c IC ' CENSUS TRACT <br /> Owner's Name �^ Phone <br /> Address City <br /> 01�Z&C;eLicense # PhoneContractor's Name 63L� �C/� _ <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC IANR SEWER LINES ,0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �f CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing �� � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation + Gravel Pack Depth of Grout Seal , <br /> Other i --. Rotary Type of Grout -2 TD <br /> Other Other Information <br /> 4 <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. is <br /> PUMP REPLACEMENT: f / State Work Done M <br /> PUMP 'tEPAIR: / / State Work Done <br /> T w` <br /> ,DF9TRUCTION 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 3 <br /> WELL DRILLERS REPORT bf .the well and notify them before putting the well in use. The above <br /> information true to the ben of my knowledge and belief. <br /> SIGNED f4) . TITLE ' <br /> kj)RAW4n2T PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: I <br /> PRASE II -GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE,: -,7_ ` 2;�t -- INSPECTION BY -42 DATE .S-- � <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ,�qa� <br /> F u I L76 5/731M 1 <br />