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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. 7 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application �'is reby-ma'de 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. F1862 and the 4les degulations of the San Joaquin Local Health District. <br /> �f�Joaquin <br /> JOB ADDRESS/,LOCATION CENSUS TRACT <br /> Owner's Name!; ' A). i Phone <br /> N .' f ja C7 r✓ <br /> Address city d <br /> -.- .. <br /> Contractor'sl, Name �� License # Phone <br /> TYPE OF WORK,, (Check) :� NEW WELL/ / DEEPEN /_% RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> 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 /> Domestic/private ` Drilled Dia, of Well Casing `~ <br /> Domestic public � .. � <br /> -- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -Z ' <br /> Other 4 �; >,. Rotary Type of Grout <br /> Other Other Information {, <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT., /.iF/ State Work Done" - <br /> PUMP REPAIR: /V/" State Work Done, <br /> e"-r - tea-rt—�• <br /> .DESTRUC_TION OF WELL: Well Diameter .1 Approximate Depth <br /> "` Describe Material and Procedure i <br /> .-4 <br /> II � <br /> I hereby agree to complyi�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 FIFTEENiDAYS <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 j. <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE ( ; <br /> j (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -- 2OR DEPARTMENT USE ONLY .. ---- <br /> PHASE I iI <br /> 00 <br /> APPLICATION ACCEPTED BY .t DATE�r%/e—7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 f �i , r 4/72 1M <br /> I � <br />