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-v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f' <br /> Telephone: (209) 466=6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 'Permit No. 15 i <br /> it <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued _ -71i <br /> (Complete In Triplicate) <br /> Application is hereby made .to the San Joaquin Local Health District.£o 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 /> d s <br /> JOB ADDRESS/LOCATION f G CENSUS TRACT S <br /> Owner's Named - Phone ' <br /> Address !g City -- R Aag) <br /> Contractor's Name Q, S , , /d� S6 A) _._ gLicense # N Phone �f�g��7 <br /> - . _ ... <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITIO ' /_7 DESTRUCTION -/� <br /> ALa <br /> PUMP INSTALLATION '/ PUMP/ PUMP REPAIR - / PUMP REPLACEMENT /? <br /> Other <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 9 Cable Tool Dia. of Well Excavation V� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Y Gauge of Casing 3 f , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information '— <br /> PUMP <br /> nformation 'PUMP INSTALLATION: Contractor <br /> Type of Pump g;P. <br /> PUMP REPLACEMENT: / P/ State Work Done <br /> PUMP REPAIR:. /State Work Done $ <br /> II <br />.DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - - - �_ Describe Material and Procedure <br /> s <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°fdfnish 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 ,TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DFX <br /> AUMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEP DATE _ ZS -7007 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � <br /> Z r. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />