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SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> tFOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:- (209) 466-6781 �lc� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7�- �S?(�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 ~JS! <br /> (Complete Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit and/or install the work herein described. This application is made in compliance twithnSanuct Joaquin <br /> Count y� dncep �2 a d t� Rules d Reguigna of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION <br /> �4-_7'- CEasUS TRACT <br /> Owner's Name Phone 36 7—3 2z7o <br /> Address ° <br /> City . -. <br /> Contractor's Name p _ License Phone3 C <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN /_7 RECONDITION /_7 DESTRUCTION- /_7 -- <br /> PUMP INSTALLATION-06;V PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / _ — <br /> DISTANCE TO NEAREST: SEPTIC TANK Alkg SEWER LINES,eAAj PIT PRIVY Vb C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C9 14d&S4 FOR- g v 1� <br /> INTENDED USE TYPE OF WELLV) : <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation / <br /> Domestic/private Drilled Dia, of Well Casing •• Ir, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal $Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ! <br /> Type of Pump ` H.P. J � <br /> PUMP REPLACEMENT: / / State Work Done f t ^— <br /> PUMP REPAIR: / / 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 know edge and belief. <br /> SIGNED TITLE c <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ITU 0VL <br /> ADDITIONAL COMMENTS: DATE �J ' <br /> PHASE II GROUT INSPECTION PHASE II /FI AL INSPECT N <br /> INSPECTION BY _�2, DATE Z-�?4j INSPECTION BY DATE J <br /> CALF. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. fl <br /> E H 1426 7/72 1M <br />