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,r <br /> 'p SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOF, F}10E USE: - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> L APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zwL6 s8fo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION 1 y/ f /L1 CENSUS TRACT <br /> Owner's Name � (�J'_ 0 So�1 Phone " 7 9.--57A � <br /> Address City <br /> License A b—ZO Phone b� <br /> Contractor's Name, 4.h. � <br /> TYPE OF WORK (Check); NEW WELL/ / DEEPEN } / RECONDITION / / DESTRUCTION I-"T <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /� <br /> Other <br /> r <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 Driven Gauge of Casing <br /> I Irrigation Gravel-Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> --- Other Other Information <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> t PUMP REPLACEMENT: }�} State Work Done <br /> r� PUMP 'tEPAIR: �-State Work Done _ ,c c zr1- �/,o <br /> DRCTRUCTION 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 /> a (DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 6� r DATE <br /> ADDITIONAL COM4ENTS: <br /> PHASE GROUT INSPECTION P S IT / NAL INSPECTWN <br /> INSPECTION BY DATE INSPECT-TON B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . _ _ 5/733.M <br />