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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 71/'3Z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - yla'"N <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zhy V <br /> 7�+ (Complete In Triplicate) <br /> Applicatio 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 �nle nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t ' �� CENSUS TRACT <br /> Owner's Name _l)4 IM4 , Phone 3 Cly <br /> Address 77 City <br /> Contractor's Name � �_ �� ,tet, L,' License #,�L,`^p� d Phone ')•--n3gY <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /Z�--PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LIES !;:- PRIVY <br /> SEWAGE DISPOSAL FIELD , /-,CESSPOOL/SEEPAGE PIT/ G} OTHER - <br /> 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAUONS � <br /> Industrial Cable'Tool Dia. of Well Excavation 1p T- <br /> v�omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout eal <br /> Other - otary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 /> info tion is true to th .est any knowledge and belief. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FO ARTMENT USE ONLY <br /> PHASE-I....___—. <br /> APPLICATION ACCEPTED B DATE 2 G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BYDATE INSPECTION BY DATE za7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �/72 1M <br />