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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf.,0FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued c� <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, 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 21 033 _S . <br /> JOB ADDRESS/LOCATION r � CENSUS TRACT <br /> Owner's Name -- .P�1,C > ( �f•C/T G� �. — Phone Z35_- 7.3 v <br /> Address _ .-. � !1�/� � - City <br /> —Contractor'-s-=Name° - (11./, -License # Phone-- w <br /> Y <br /> TYPE OF WORK (Check) : NEW WELL /!i/� DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLfi1P REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /2pPIT PRIVY <br /> �( SEWAGE DISPOSAL FIELD fkl CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /011 ~ <br /> Domestic/private Drilled Dia. of Well Casing 6, -5; " Q <br /> Domestic/public Driven Gauge of Casing /z 1019 <br /> Irrigation Gravel Pack Depth of Grout Seal _ 4[) ' <br /> Other _ V Rotary Type of Grout <br /> Other Other Information <br /> PUAiP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done UMP mo T iW ` <br /> y <br /> PUMP TiEPAIR: /—/ State Work Done <br /> ,DFCTRUCTION 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 tr to t/he} best <br /> ^'J1ofJ®m(jf�/ �knowleddge and belief. <br /> y �/PV/ ♦ N'`.l,.i/Ll/✓4 4•'L'f � ��(VL!I �/�j� <br />{ SIGNED , TITLE VA <br /> f DRAW LO PLAN ON REVERSE "SIDE) <br />;. <br /> F2:11 DEPARTMENT USE ONLY <br /> f PHASE I ; G <br /> APPLICATION ACCEPTED BYDATE d� <br /> DITIQNAL GQ► � T S: 2e7� c a•� W C <br /> P E ROUT INSPECTI N P I/ AL INSPECTION <br /> INSPECTION. BY ,�. DATE - INSPECTION DATE --Z <br /> t q <br /> CALL FOR A GROUT INSPECTION PRIOR TOG 7 ING AND FINAL INSPECTION. r; <br /> E 14 1426 '• ,�... 5/731M <br />