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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E 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 EXBIRES l YEAR'FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San' J"oaquin 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 f if /a Se or, ���©�`� n/o,4 A rz,91b.- CENSUS 'TRACT <br /> Owner's Name -04XI Phone <br /> Address ' m Y (941 - City <br /> Contractor's Name �,�.. - License # 1 ys'Phone -7-- 767 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /� �l <br /> PUMP INSTALLATION / / PUMP REPAIR L�f PUMP REPLACEMENT 1_7 Th <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 �Y — <br /> Domestic/private Drilled Dia. of Well Casing . <br /> Domestic/public Driven a Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Other Rotaiy Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> ! Type of Pump H.P. �fp <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done Ea <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l <br /> ;*I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4'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 d belief. <br /> SIGNED � � .s - - ITLE ��° <br /> ( RAW PLOT PLAN ON R V RSE SIDE <br /> ' &01 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION I PHA II INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE d <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br /> 7/72 1M <br /> � E H 1426 r ," � .. �� �n � 7 <br />