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SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> FOF,:O.FFICE USE: 1601 E. Hazelton Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zr- ,q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z .g3-7 3 <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 /> Count _ Ordinance No...1862,�-and the Rules and Regulations of the San Joaquin Local: Health District. <br /> - <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION �+ <br /> J <br /> owner's Name �� 1--��© e, � 1 V f ) Phone---- -� <br /> Address S CCI. fir- / � �' City-- -�-- -- <br /> Contractor's Name/ a CL1�G License # Phone <br /> } <br /> TYPE OF WORK (Check): NEW WELL/ / DEEP N jT RECONDITION / /? DESTRUCTION j7 <br /> PUMPZINSTA LATION / / PUMP REPAIR L1 _1 PUMP REPLACEMENT j7 <br /> Other,/ / <br /> DISTANCE TO NEAREST:. SEPTIC, TANK ,. EWER LINES PITIPRIVY rr- a.:. <br /> SEWAGE_D.ISFOSAL "FIELD-----1 CESSPOOL/SEEPAGE PIT /0 0 OTHER <br /> INTENDED USETYPE"OF WELL ti ' w CONSTRUCTION SPECIFICATIONS <br /> Industrial , 6. Cable Tool. � � Dia.f of Well. Excavation <br /> Domestic/private f i Drilled ;, D%a.roof Well Casing <br /> Domestic/public L,, 'Driven G Gauge-of Casing <br /> Irrigation i Gravel Pack Dep W of Grout Seal ? <br /> Other �` Rotary,,,---4 TypOf Grout , <br /> i 7z Other L ,�\ Other Information <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump Tc H.P. <br /> PUMP REPLACEMENT: ` / / State Work Done j <br /> PUNIP"` PAIIt: �_ - "/ / State Work Done <br /> .DFgTRUCTION 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 Califonilia 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 /> 3 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; SIGNED ' TITLE <br /> r W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �J <br />' PHASE I DATE/ <br /> Z- ,l <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS.- <br /> PHASE II G PHASE II/FIN INSPECTION <br /> F INSPECTION BY DATE INSPECTION BY DATE <br /> - CALI, F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> -- _ , <br /> 5/731-M <br />