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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br />! <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. �,7_/,23 <br /> ` I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (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/LOCATION <br /> CENSUS TRACT <br /> f — <br /> Owner's Name L <br /> Phone <br /> F Address <br /> City <br /> Contractor's Name ^fir f� _S U Z7--,0 o License # q222oLpPhone <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /� RECONDITION / j DESTRUCTION 1-7PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> +, Other i/% <br /> -..,,STANCE TO NEAREST: SEPTIC "tTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 0 }ri <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial E Cable Tool Dia. of Well Excavation S <br /> Domestic/private ! Drilled rDia. of Well Casing ' <br /> Domestic/public 3 Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack - - Depth of Grout .-Seal <br /> Other ! Rotary .,. r Typi, of Grout <br /> « r <br /> Other 0ther Information E <br /> PUMP INSTALLATION: 'Coznkrac for O <br /> B <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br />-PUMP-REPAIRS °°` //'"rS-tate-Work -Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure h <br /> i <br /> I hereby agree to comply withlall 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 <br /> TITLE <br /> (DRAW PLOT FLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � / DATE -_,36- 7� <br /> ADDITIONAL COMMENTS: % III <br /> PHASE II GROUT INSPECTION HAS PTF/eVINALIN SPECTION <br /> INSPECTION BY DATE NSP! 6 :T[?N�d3XY DATE .., , <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 <br /> 7/72 1M C4Z�)- <br />