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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.TOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a_/- ,I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby -made t 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 /> 1 <br /> JOB A -CENSUS TRACT ,ADDRESS/LOCATION ��� �',� % ,��� Q., _ <br /> Owner's Name � �Ge� a '" Phone <br /> Address _ i2��✓ � .414n T^ City r �_ <br /> Contractor's Name T License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC]TANK SEWER LINES PIT PRIVY <br /> w SEWAGEiDISPOSAL 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 v1 <br /> Domestic/public Driven Gauge of Casing <br /> r <br /> Irrigation Gravel Pack' , Depth of Grout Seal <br /> Other ! Rotary Type''�of 'Grout <br /> I Other Other Information <br />{ PUMP INSTALLATION: Contractor <br /> - 'Type of'Pump --- - - -- - ._. <br /> PUMP REPLACEMENT: / State Work Done _J <br /> I PUMP UPAIR: / 7 . State Work Done - } <br /> i ,DESTRUCTION OF WELL: Well Diameter :: .r « T z t Approximate Depth, <br /> Describe Material and Procedure f . , <br /> I herebyagree to comply withh,,all,.law -and„_re. ulati.on.s-bf the San Joaquin Local Health District <br /> S P Y �.. q _ <br /> and the State of. California pertainingto or regulating well ''constructfon. Within FIFTEEN DAYS <br /> t after completion of my work on a new well, I will furnish the San Joaquiri' Loca1 Health District a, <br /> WELL DRILLERS REPORT; of-the'we11_arid-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 T- <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATES-? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '-71-7 6 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426' 5/731M <br />