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JOAQUIN LOCAL HEALTH DISTRIC+ <br /> FOR OFFICE USE: 16t -, E. Hazelton Ave. , Stockton, Ca Lf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13- tj� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) � 7 <br /> f Application is hereby made to the San Joaquin Local Health District fa <br /> 3ndjor install the work. herein described. P t o co truct <br /> 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 /> JOB ADDRESS/LOCATION X70 / CENSUS TRACT 5 q <br /> l <br /> Owner':s Name >al <br /> �° Phone <br /> Address17 <br /> I° City -47 o <br /> Contractor's NameSI ,rte License # Phone <br /> TYPE OF WORK (Check); NEW WELL /-7 DEEPENRECONDITION /-7 DESTRUCTION /? <br /> I <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNE5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE a TYPE <br /> IndOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> DDomestic/private " Drilled Dia, of Well Casing <br /> omestic/public Driven - - --1 ---- <br /> Gauge of Casin _ l® <br /> - Irrigation g <br /> Gravel Pack Depth of Grout Seal — ` <br /> Other _ Rotary Type of Grout <br /> Other <br /> _ Other Information <br /> €3 <br /> PUMP INSTALLATION: Contractor <br /> -- _._ Type of Pump H.P. <br /> PUMP REPLACEMENT: / !/ State Work Done <br /> PUMP RE—PAIR. 15a.1 State Work BoneJoWp <br /> PESTRUCTION OF WELL:." Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 DRIL PORT of the well and notify them before putting the well in use. The above <br /> a, on t e to t of m <br /> infory owledge and belief. <br /> j <br /> SIGNED. <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> !j FO DEPARTMENT USE ONLY <br /> Pi�ASE I:� . <br /> APPLICATION ACCEPTED B r � <br /> ADDITIONAL COMMENDATE TS: _7-3 <br /> PHASE II. GROUT INSPECTION <br /> INSPECTION BY PHASE II NAL_ INSPECTION <br /> DATE INSPECTION BY l/�_ DATE el <br /> CALLFOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 2 7/72 1M k <br />