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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FDF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Jar -38f� <br /> r <br /> THIS PERMIT :EXPIRES l YEAR FROM DATE 'ISSUED Date Issued 7- 5l <br /> (Complete In Triplicate) <br /> Application is hereby madelto 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 Joaquit <br /> Count Ordinance No. 1862 and the Rules and Regulations of the San-Joaquin Local, Health District. <br /> .TOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> r <br /> Address eyl!2- rl0 -3 City ' <br /> Contractor,'s Name � lL E)17 L -- -- License Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / { DESTRUCTION J f Y <br /> PUMP INSTALLATION / I PUMP REPAIR / I PUMP REPLACEMENT <br /> Other <br /> --- <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 I Cable Tool Dia. of Well Excavation I/ <br /> ___ iDomestic/private __LL,-Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - - - Irrigation Gravel Pack Depth of Grout Seal C <br /> Other T�Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'UMP `tEl'AIRi / / 'Staten4brk-Done <br /> ,DFRTRUCTION 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 /> s 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 /> I <br /> SIGNED �� � '7Q _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I; _ <br /> APPLICATION ACCEPTED BY �/T+ �" DATE <br /> ADDITIONAL COMriENTS: <br /> P I GROUT INSPECTION PHA I/FINAL INSPECTION <br /> INSPECTION BY DATE . �/ r 2 INSPECTION SY <br /> � DATE p- <br /> CALL FOR A GROUT- INSPECTION PRIOR-TO GROUTING AND FINAL INSP ION. <br /> E-H 1426 5/731M <br />