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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.,OIF'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na.�3 SLIJ <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED Date Issuedlo zL <br /> (Complete In Triplicate) <br /> Application is hereby spade 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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ -- ' cENsus TRACT0 L`-03y-3 <br /> � ' <br /> Owner's Name .i7_ 't,. `Z j✓ Phone <br /> �+® • <br /> 4 <br /> Address _r. .�� `t7y,fl }/..'.l' � a_r0 r>jCity . . <br /> Contractor's Name —`�j�J _ License # �7�iRhone <br /> T � <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION { / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <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 f' ---- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout Py r� , <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> �"�-�C �J'�,'�, � �� - S���V�� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DFgTRUCTION 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 />'E information is true to the best of my knowledge and belief. <br /> s SIGNED C,Q ° TITLE <br /> kbW PLOT PLAN ON REVERSE SIDE) - -- <br /> F04 DEPARTMENT USE ONLY <br /> T <br /> PRASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �7 <br /> CALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. <br /> T11 IT 1 1")r E,/71'i w <br />