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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> 70 .,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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. 1.862 a: d the Rules and Regulations of, the-San .Joaquin Local health District, <br /> t`=. s..._ . L". <br /> JOB ADDRESS/LOCATION Aj Ail <br /> �- ENSUS TRACT s` <br /> Owner's Name1A, Phone -Zy7-02- -o/ <br /> Address (Oc/ ' <br /> a{ City -f-5 CALF �. <br /> Contractor's Name 1. Qr��y� -- License #,? D/QPhone <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /-" <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other PUMP REPLACEMENT /- # <br /> - /% <br /> DISTANCE TO NEAREST: SEPTIC- TANK SEWER LINES PIT PRIVY ` 1 <br /> - 4 y SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industridi - Cable 'tyf`Wel]"Excavation <br /> Domestic/private mak; _ Drill-e-d Dia. of Well Casing <br /> Domestic/public ' Driven - Gauge of Casing <br /> Irrigation 1 Grav&I Pack Depth of Grout Seal <br /> Other ! Rotary ,/Type of Grout <br /> f Other Other Information t <br /> PUMP INSTALLATION: Contractor . <br /> Type 8f <br /> Pump H.P. : i <br /> PUMP REPLACEMENT:--:.,,,;, / j State Work Done ' t <br /> PUMP UPAIR:-- -7- State Work Done .PIpQ Y�P 0 �-� - ---- <br /> .DFGTRUCTION OF WELL: Well Diameter <br /> 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 i <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 theme before` putting the well in use. The above <br /> information s true to he best of my knowledge and belief. <br /> SIGNED TITLE <br /> i DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EP NT USE ONLY <br /> Pl3ASE I 1 <br /> APPLICATION ACCEPTED . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONP S II%NAL INSPECTION <br /> INSPECTION BY DATE INSP DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426-. r- i7�,.. <br />