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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7c1_S"/'P41) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 27-7 4 <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 tej ides and Regulations of the Sari Joaquin Local. Health District. <br /> JOE LOCATION .'.r '""_ j 2 r CENSUS TRACT <br /> Owner's Name Phone <br /> Address — 1��G1/` City _ <br /> Contractor's Name tug" �/ �l sf! License 1�7M/Phone,,�7� <br /> TYPE OF WORK (Check): NEW WELL DEEP / I RECONDITION /_7 DESTRUCTION / <br /> PUMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other 177 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY �7 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT�� OTHER 4 <br /> r <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 - z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �7f <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done <br /> ,DESTRUCTION 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 G <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTI10N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ,3 � INSPECTION BY �� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />