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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF- or." TCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZM-_-5 ,770 j <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued/12__ _7!_ <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. - Thisap lication is made in compliance with San Joaquin <br /> County Ordinance No. 8 d � Ur <br /> 1(d uwtio 6_% he San Joaquin Local Health District. <br /> JOB- a ADDRESS/LOCATION —'� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor`s Name 0de_11_e1x1-* License hone - <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /_/ DESTRUCTION %f <br /> PUMP INST TION / / PUMP REPAIR / / PUMP REPLACEMENT' /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINF/,S PIT PRIVY (, <br /> SEWAGE DISP SAL FIELD Z/n'} SSPOOL/SEEPAGE PIT ,OTHER �V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In tial Cable Tool Dia. of Well Excavation l!� <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout -- - <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor tS � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done rh <br /> PUMP U-PAIR: / / State Work Done � r <br /> DFSTRUCTION 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 welland notify them before putting the well in use. The above <br /> information true to the be of my knowledge and belief. <br /> SIGNED TITLE <br /> Al <br /> _. kDRW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Ir"od? DATE �G <br /> ADDITIONAL COMMENTS: S>lg/ <br /> PHASE 11 GROUT INSPECTION Mse III/FINAL INSPECT12 <br /> INSPECTION BY __. �. _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> -E it: 4 <br /> 126 <br /> - - - 5/731M <br />