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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 F. Hazelton Ave. ,',Stockton-,,- Calif. <br /> Telephone: (209) 466 -67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lir, � <br /> THIS PERMIT EXPIRES 1 YEAR 'FROM- DATE 'ISSUED Date Issued . <br /> '(Complete In Triplicate) <br /> Application:=is .hereby­made,to the San.,J©aquin 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. ,1$622 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c�LJ --+ P/C_rr!U CENSUS TRACT <br /> Owners Name �./ (�a `Y' s Phone <br /> iN <br /> Address A%I. Q� .�-�. City 42 �� <br /> Contractor's Name � License iCPhone <br /> TYPE OF WORK (Check) : NEW WELL/�(' DEEPEN / / RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_T <br /> Other <br /> II <br /> DISTANCE TO NEAREST: SEPTIC TANK ' `SEWER LINES PIT PRIVY <br /> . f SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> I . - . <br /> INTENDED USE - TYPE -OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia-:`of Well 'Excavation <br /> Domestic/private Drilled Dia. of'We1-1 Casing <br /> Domestic/public Driven #' Gauge of- Casing <br /> Irrigation Gravel Pack Depth,46f Grout Seal per' T <br /> Other <br /> V Rotor T e� of Grout _ <br /> u y W- yp <br /> !� F OtherOther Information' <br /> PUMP INSTALLATION: Contractor ,TOe, /�!d_�_!'_.L -_ <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: S tate' Work Done .' <br /> PUMP REPAIR: / I/ State Work Done + A <br /> .DESTRUCTION OF WELL: 111-D` iame-ter�_ _ t '_; •` -- Approximate Depth <br /> # <br /> Describe Material and Procedure <br /> 49 <br /> I hereby agree to complydwith' alltlaws and regulations of the San Joaquin Local Health District <br /> and the State of Californi p rtaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a newswell, 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 trueto t e be t .af my knowledge and belief. <br /> SIGNED TITLE <br /> ! ; (DRAW PLOT PLAN ON REVERSE SIDE) s <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I 9�XT � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 11 <br /> ,PHAS9 TI 9ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /® <br /> CALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. . .. <br /> E H 1426 4/72 1M <br />