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369 Yooq <br /> 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 /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7--iT->% <br /> (Complete In Triplicate) �-S'F - (070-f- <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 Regul t ons of -he San Joaquin Local Health District. <br /> -1.3(4'2_:,0-,oZj:.�-c <br /> ,TOB ADDRESS/LOCATION CENSUS. TRACT <br /> Owner's Name Phone <br /> Address City <br /> C <br /> Contractor's Name 7 7 c/ <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 w <br /> Other —/—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK�n SEWER LINES 0 PIT PRIVY <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> h <br /> Industrial TYPE OF WELL CONSTRUCTION SPECIFI ATIONS <br /> Industrial ale Tool Dia. of Well Excavation jq <br />�mestic/private s Drilled Dia. of Well Casing C3 F <br /> Domestic/public I Driven Gauge of Casings <br /> v <br /> Irrigation IGravel Pack. Depth of Grout Seal �� t ! <br /> Other Rotary Type of Grout ' <br /> Other Other Information <br /> w <br /> PUMP INSTALLATION: Contractor <br /> j7 <br /> Type of Pump <br /> H.P. +, <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PU14P-REPAI-R.-----` r: <br /> / / St4te-Wark-Done. - <br /> ESTRUCTION 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 true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ' <br /> FOR DEPARTMENT USE ONLY <br /> °. <br /> APPLICATION ACCEPTED BY DATE 7V <br /> ADDITIONAL COMMENTS: ---�— 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL- INSPECTION. <br /> E H 1426 7/72 1M <br /> 0 <br />