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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOL OFFICE USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--3p p4J <br /> THIS PERMIT EXPIRES I 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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations o the San Joaquin Local Health District. <br /> k JOB ADDRESS/LOCATION D 01.v CENSUS TRACT ' <br /> Owner's Name . Phone <br /> Address , L� ! ! City C° <br /> Contractor's Name W O O d s Li' <br /> Contractor <br /> w A. �}EEPENI /"^ItECONDITION.�/%—DESTRUCTION,JET--� y�• a- - ,.r <br /> TYPE OF WORK" (Check)T--`NEG3TWLLL/ _ <br /> PUMP INSTALLATION )!;;?'PLW REPAIR / / PUMP REPLACEMENT 17 <br /> ,,Other <br /> � <br /> TANK SEWER LINES [�L.r1 PIT PRIVY DISTANCE TO NEAREST: SEPTIC .�� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial :, <br /> Cable Tool Dia. of Well Excavation 'Sk <br /> k_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge .of Casing A <br /> Irrigation ,. Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �,ou selayllX��I <br /> — Other Other Information ' <br /> { <br /> WOODS . . <br /> PUMP INSTALLATION: ' Contractor <br /> , Type of Pump - H.P. /� ► <br /> PUMP REPLACEMENT: / / State Work Done <br /> ,PUMP `4PAIR: w / State Work Done <br /> E Approximate Depth <br /> DF-,TRUCTION OF WELL: Well Diameter <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 /> 14ELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is -tru.e 'to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE <br /> {DRAW FLUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P 1111 S E I DATE?�� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS. PHASE III/FINAL INSPECTION <br /> C PHASE II GROUT INS CTIO <br /> } INSPECTION BY DATE Z7 <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> 5/731M <br /> E H 1426 - <br />