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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. � <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 Joaquinj <br /> County Ordinance No. 1$62 and tho $u3es and Regulatlons of the San Joaquin Local Health District. <br /> /6P65-- ^ of a e <br /> JOB ADDRESS/LOCATION 6L`f S 7 e'F S d Gr> 1R D CENSUS TRACT <br /> Owner's Name Phone i <br /> - - Ay 1- . ._..., ...4� 000N ACI &Address city <br /> Contractor's Name akil V Pr5a 1 I &t-Vl S� /� License �i` Phone�b4 9 <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION Ld ` <br /> PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 5( Domestic/private Drilled Dia. of. Well Casing. <br /> Domestic/public Driven Gauge of Casing S� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information t�1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �' H.P. <br /> PUMP REPLACEMENT: / / State Work Done c <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 knowledge and belief. <br /> f y <br /> SIGNED ITLE <br /> D W LOT PUATq,ON REVERSE SIDE <br /> FOR 2&PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L LF <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br />, INSPECTION BY DATE INSPECTION BY DATE <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. � <br /> E H 1426 7/72 1M <br />