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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 4) <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 District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with Sao, Joaquin <br /> County Ordinance No. - 1$62 and the Rules and Regulations of the San Joaquin Local Reolth District. <br /> JOB ADDRESS/LOCA'TION - - ente _/ ww1r _ JA� � - CENSUS TRACT <br /> Owner's Nance r � Phone <br /> Address — � 42/' 0 ' -- WA. City <br /> . /, / f <br /> Contractor's Name' pzfeed . d / License Phone 6� <br /> TYPE OF WORK (Check) : NEW WELL - DEEPEN "/- / RECONDITION /_% -DESTRUCTION /_ <br /> PUMP INSTALLATION jr/ PUNP REPAIR/ / PUMP REPLACEMENT /? <br /> O they <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ,_ CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial Cable Tool Dia. of Well Excavation d <br /> Domestic/private Drilled Dia. of Well Casing j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation' Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout / <br /> Other 4 Other Information ' <br /> s <br /> PUMP INSTALLATION: Contractor � . . <br /> Type sof Pump H.P. .�., <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP VPAIR: / / State Work Done R <br /> DF"-TRUCTION 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 workf'on a new well, I will furnish'the San Joaquin Local Health District a <br /> WELL DLL- REPORT o€ -the well. and Notify them before putting the well in use. The above <br />` informa on is tru o t best of my knowledge and- belief. <br /> E <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN- ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> G PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE Ij GROUT INSPECT N PHASE IIT/FINAL INSPECTION j <br /> INSPECTION BY ! DATE ,'.r INSPECTION BY DATE -7$1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F T-T IA94 1� /7'A7-A <br />