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SAN JOAQUIN LOCAL HEALTH DISTRICT RI <br /> FOR OFFICE 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 <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 Dlkrict. <br /> JOB ADDRESS/LOCATION :21 `_2 5 0 N - CENSUS TRACT S <br /> Owner's Name jjtM B 9/I= I Phone <br /> Address City �I �C�1'f� <br /> Contractor's ,Namey��fj]fj/1f�,� ?r}� , l License # Phone <br /> //(�, �� <br /> If <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_/ RECONDITION /� DESTRUCTION IJT <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �'- <br /> Industrial Cable Tool Dia, of Well Excavation // <br />` Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ 62 _L1 <br /> f Irrigation Gravel Pack � Depth of Grout Seal <br /> Other Rotary Type of Grout 4rEWL0N16C_ --- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT, / / State Work Done <br /> PUMP-REPAIR-a....,.., —St-ateFWork Dover <br /> � .AESTRUCTION 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 FIF'T'EEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distritt 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 PIAN ON REVERSE SIDE <br /> FOR DEP T T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE 11 GROUT INSPECTION F /IIi F AL INSPECTION <br /> ' INSPECTION BY _ DATE INSPECTIONBY �V DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M. <br />