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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 /> 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 Distract 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 106 4-4NSUS TRACT <br /> ;} Y <br /> Owner's Name S, ,/D, dzc-&L Phone _50 <br /> II0o J� f� J <br /> Address Lip/ 1 �p��`�21o3� 1� ®� City ma,17 e__C— <br /> Contractor's Name j M..Z <br /> License #J0_LZ_37Phone <br /> TYPE OF WORK (Check): NEW WELL :6-- DEEPEN / / RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY E <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> - Industrial, Cable Tool Dia, of Well Excavation i <br /> _ Domestic/private Drilled Dia, of Well Casing m <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r d <br /> Other Rotary Type of Grout _Q <br /> c <br /> Other Other Information <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> J <br /> PUMP REPAIR: / / State Work Donef <br />,DESTRUCTION 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 DAYS4 °} <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 /> FOA DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAU ,I GROUT INSPECTION PRASE II/FINAL gNSPECTION <br /> INSPECTION BYDATE INSPECTION BY GT _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �Q ?,3 4r 7/72 Im <br />