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SAN JOAQUIN LOCAL HEALTH DISTRICT.- <br /> FO,4 7F'1 E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6783 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued za_. J_ �-s <br /> (Complete In Triplicate) <br /> Application is hereby made �o the San Joaquin Local Health District for a permit to construct <br /> aad/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 Sari Joaquin Local. Health District. <br /> i �J <br /> JOB ADDRESS/LOCATION / c�Gf� % ` CENSUS TRACT <br /> 'Owneris Name1 Phonet3/ � <br /> Address <br /> a / <br /> Contractor's Name T > /�t/ ��s } License # ���373 Phone'-g a <br /> =TYPE OF-WORK -(CRdck) - 'NEW`WEEL�-/ J -DEEPEN /_ MP 7 RECONDITION /_/ —DESTRUCTION /-7 <br /> AL - _ <br /> PUMP►INSTLATION / J PUREPAIR . PUMP REPLACEMENT /- <br /> k Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> 1 Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> j Other Other Information <br /> 1 r <br /> PUMP INSTALLATION: Contractor <br />! Typetof Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> a PUMA "REPAIR: /��"'S't�`t�`Work Donee/ `-`j� t/y�•�' ����y .. .�,._ <br /> DFRTRUCTION OF WELL: WelliDiameter Approximate Depth <br /> EDesciribe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i <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 thelwell 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 <br /> (DRRAAV PLOT PL ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PRASE I' <br /> APPLICATION ACCEPTED .B IT, J • DATE /c �-3 <br /> ADDITIONAL C04MMENTS: 1 <br /> PHASE II GROUT INSPECTION PEgLy NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN I <br /> ,s E H 1426 K/731M <br />