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SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> I <br /> THIS PERMIT EXPIRES l YEAR. FROM DATE ISSUED n. 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 District. <br /> JOB ADDRESS/LOCATION � „�. rax I�ZD Gl �cecENs�s TRACT ` <br /> Owner's Name 72 <br /> F AlIEZ ' -S Phone <br /> Address L. , C� City <br /> Contractor's Name LAAz� _W/ License # �714111�7 Phone !Z,/ <br /> k <br /> t TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /"7 .._ � <br /> l PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /77 <br /> 1 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 Too.. Dia.,'of W611 Excavation -Z:y-• <br /> Domestic/private Drilled Dia, of Well-'Casing <br /> Domestic/public Driven Gauge of Casing r 5-6 Irrigation Gravel Pack - Depth of Grout Seal i <br /> Other Rotary _ ;Type of Grout'. <br /> _ Other Other Information 1 <br />{ PUMP INSTALLATION: Contractor <br /> I <br /> Type of Pump _ - H.P. <br /> a PUMP REPLACEMENT: =` % / State Work Done <br /> PUMP REPAIR: / / State Work Done �. <br /> ,DESTRUCTION OF WELL: i Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> z <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 /> j WELL DRILLERS REPORT of- the well and notify them before putting the well in' use. The above <br /> information is true to the bestf my knowledge and belief. <br /> s.n <br />� SIGNED TITL <br /> .. r.-• <br /> GZ"' <br /> (DRAW/PLOT PLAN ON REVERSES DE b <br /> PHASE I <br /> FOR DEPARTMENTUSE ONLY <br /> APPLICATION ACCEPTED BY DATE l �� <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PRA E I/ FINAL INSPECTION <br /> INSPECTION BY _ DATE 'INSPECTION BY C DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E E H 1426 <br />� 7172 1M <br />