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' SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> Fd . OFFICE: USE: -1601 E. Hazelton Ave. , Stockton, Calif, <br /> ' Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zr <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone 1,1 <br /> Address -- <br /> _ city <br /> f'lf/ Yq <br /> Contractor's Name ,r.� License # 1,267,,7 Phone <br /> TYPE OF WORK (Cheek) : NEW WELL &11 DEEPEN '/ / RECONDITION f_1 DESTRUCTION Jam" <br /> PUMP INSTALLATION / / PUMP REPAIR '/_/ PUMP REPLACEMENT /_7 <br /> Other / /' <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> a SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> �..� 3 k Cable+Tool Dia. of Well Excavation . <br /> r Domestic/private Drilled Dia. of Well Casing Id m <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation W Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout ` <br /> Other, Other Information ' <br /> PUINT INSTALLATION: Contractor <br /> Type of Pump <br /> I H.P. <br /> PUMP REPLACEMENT: / j State -Work-bone' - 4 <br /> PUMP UPAIR: J / State Work Done <br /> .DF<TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> o <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 i <br /> -after completion of my.work on a new well, I will furnish the San Joaquin Local Health District a s <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 /> t <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE} - •_ - { <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY <br /> DATE `75 <br /> ADDITIONAL COMMENTS: - - — <br /> { <br /> PhAa II T P •CTI N _ / Vz e-C-1 Ct?'a PHASE IIIJFINAL INSPECTION # <br /> INSPECTION BY / DATE - INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR .TO GROUTING AND FINAV INSPECTION. • ! <br /> E H 1426 .�f- t�..rl cf.Ir Q�/1-/771 " e /7 <br />