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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 1 " <br /> ✓` ���� \:THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-)[•-7 L <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �Z0 CENSUS TRACT <br /> Owner's Name �� �� p w �L Phone (off <br /> Address City <br /> ;�C=��r�f, j � . City Q <br /> Contractor's Name E� ��/( E � License # Phone 7� o <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / 7 a <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK � <br /> SEWER LINES � PIT PRIVY J 5 ,�. <br /> SEWAGE DISP SAL FIELDS(� CESSPOOL/SEEPAGE Pk— OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ar Domestic/private Drilled_ Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j(J <br /> Irrigation Gravel Pack Depth of Grout SealrJ� p <br /> Other _ Rotary Type of Grout AceS <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor lv o(j- <br /> Type of Pumpg�(� ki H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> 'L <br /> PUMP REPAIR: f-1 State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter �j �� 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 otifthem before putting the well in use. The above <br /> information is a to the bes� of kno edge and belief. <br /> SIGNED ,' 0• TITLE C ✓�- <br /> (DIMIJ PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -a c',? ? INSPECTION BY DATE -3 -7Z— <br /> CALL <br /> 7ZCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />