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XSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_:O OFICI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 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 /,2_ ,rka--76 <br /> (Complete In Triplicate) 2.0 - tic__3 <br /> Application is hereby Made to the San Joaquin Local Health District for a pergi.t 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 /> 4� <br /> JOB ADDRESS/LOCATION ' SUS TRACT - <br /> Owner's Namei, Phone <br /> r Address City <br /> Contractor's Name A / _ _ _ License 6 Phone <br /> /_/ /�T <br /> TYPE of WORK (Cheek) : NEW WELL / / DE ! /EPEN RECONDITION DESTRUCTION <br /> f PUMP INSTLATION �/ PUMP REPAIR / PUMP REPLACEMENT / <br /> AL <br /> ' Other <br /> I 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i <br /> Drilled Dia. of Well Casing <br /> �a <br /> Domestic/private g <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> —Othe.r-- Rotary Type of Grout <br /> Other ~- Other Information ' <br /> ' PUMP INSTALLATION: Contractor �" � �� <br /> Type of Pump I' - q0 H.P. <br /> PUMP REPLACEMENT: State Work,Done - � !!J /Q U <br /> v y <br /> PUMP *tEPAIR: / / State Work Done * f <br /> s DF�TRUCTION OF WELL: Well Diameter ;f Approximate Depth <br /> f 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 we11 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new 1�rell., I will -furnish-the San Joaquin Local Health District <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 /> �("� 1Y <br /> SIGNED % TITLE.' �(�'� pa-� InJ.0- <br /> 6RAW PLOT PLAN ON REVERSE SIDE} Y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kF APPLICATION ACCEPTED BYlz,e?9fDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE III'/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE I�- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />