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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �P2-/-ZS�J� <br /> THIS PERMIT EXPIRES 1" YEAR FROM DATE ISSUED Date Issued!a-3/- L <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/LOCATION 'yKj <br /> CENSUS TRACT <br /> Owner's Name Phone �/ -��7 <br /> S <br /> Address City } ,Zo 6: <br /> 5 <br /> Contractor's Name 71� .�.,�fJei.J • �� -- -_ License Phone <br /> TYPE OF WORK (Check) :. NEW WELL /� DEEPEN_ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION % / PUMP REPAIR / / PUMP REPLACEMENT, <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS %,J <br /> Industrial Cable 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 Rotary Type of Grout m . <br /> Other Other Information <br /> O <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP-•REPAIR: /-77--state Work Done <br /> ESTRUCTION 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 <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 A `TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: -w'. ' <br /> PHASE II GROUT INSPECTION PHASE 11 T'�ALINSPECTION <br /> INSPECTION BY DATE NSP_ DN Y ATE <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> i <br /> 7/ 1M <br /> E H 1426 <br /> i <br />