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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOR OFFICE USE: �16�e E. Hazelton Ave., Stockton, Calf. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J j <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />(Complete In Triplicate) Y-7 3 <br />Application is hereby made to 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 />i v / i • _i i le). -,e2 - <br />JOB ADDRESS/LOCATION <br />Owner's Name <br />Address <br />Contractor's Name <br />TYPE OF WORK (Check): NEW WELL / / DEEPEN <br />PUMP INSTALLATION <br />Other <br />CENSUS TRACT <br />Phone <br />City <br />License Ila5-Sf77 Phone <br />/% RECONDITION /-7 DESTRUCTION /7 <br />PUMP REPAIR REPLACEMENT <br />PUMP INSTALLATION: Contractor <br />Type of Pumps LVYlZ Yl L <br />PUMP REPLACEMENT: / / State Work Done <br />PUMP REPAIR: I-V State Work Done a <br />,DESTRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure <br />H.P. <br />IL - <br />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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />information is tryW�to the best eflny knowlgdRe and belief. <br />SIGNED <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II G. <br />INSPECTION BY <br />r `CA-,Od TITLE <br />RAW PLOT PLAN ON REVERSE SI'. <br />INSPECTION <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br />E H 1426 <br />DATE 7 <br />4/72 1M <br />19 <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER <br />LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD <br />_ <br />CESSPOOL/SEEPAGE PIT OTHER <br />Cj <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Industrial <br />Cable Tool <br />Dia, of Well Excavation <br />_k�' Domestic/private <br />Drilled <br />Dia. of Well Casing <br />Domestic/public <br />Driven <br />Gauge of Casing <br />Irrigation <br />Gravel Pack <br />Depth of Grout Seal <br />Other <br />Rotary <br />Type of Grout <br />Other <br />Other Information <br />PUMP INSTALLATION: Contractor <br />Type of Pumps LVYlZ Yl L <br />PUMP REPLACEMENT: / / State Work Done <br />PUMP REPAIR: I-V State Work Done a <br />,DESTRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure <br />H.P. <br />IL - <br />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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />information is tryW�to the best eflny knowlgdRe and belief. <br />SIGNED <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II G. <br />INSPECTION BY <br />r `CA-,Od TITLE <br />RAW PLOT PLAN ON REVERSE SI'. <br />INSPECTION <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br />E H 1426 <br />DATE 7 <br />4/72 1M <br />