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� JOAQUIN LOCAL HEALTH DISTRIC" <br /> cOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal�i'f. <br /> — Telephone: (209) 466-6781 $ 3-%5 <br /> —' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6��72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued OJ <br /> (Complete In Triplicate) <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �i7 (I�rc �YCENSUS TRACT p <br /> �ZsIiq.n�g Phone <br /> Owner's Name - {� ' <br /> Address <br /> S3 G Z City � <br /> �'�--� License 1j,2/�SV1Phone <br /> Contractor's Name4."4 £ r <br /> TYPE OF WORK (Check) -. NEW WELL / / DEEPEN / / RECONDITION_/ / DESTRUCTION /-T <br /> PUMP INSTALLATION j/ PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation J\ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> • J <br /> PUN2 INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done)x , <br /> DrqTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws acid 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to he est of Ay knowledge and belief. C �O <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I �( �a DATE 4-I1-3 <br /> APPLICATION ACCEPTED B ---- <br /> ADDITIONAL CONa ENTS: PHASE II NAF, INSPECTION <br /> PHASE II GROUT INSPEC IOV INSPECTION BY DATE o7 gZ <br /> INSPECTION BY DATE ,® <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.' 5/73LX <br /> I l nO <br />