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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.. . ,,1. 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,/,a_—. ->- <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 f CENSUS TRACT <br /> r <br /> Owner's Name ? �LSC�2 `_ —_ Phone <br /> Address T_ City 4 CSCAZ n) <br /> Contractor's Name ,� License #q2,?2V/v Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT /-7 <br /> Other / / <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 Cable Tool Dia. of Well Excavation V1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation: ' Gravel Pack Depth of Grout Seal. <br /> Other 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 /> 3crr 7- <br /> PUMP <br /> PUMP REPAIR: / / State Work Done <br /> jDESTRUCTION 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 Loca1 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 /> SIGNED / 1 &-- _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I�% <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i q \^ ®n - <br /> APPLICATION ACCEPTED BY 1�1� DATE 10 <br /> ADDITIONAL COMMENTS. <br /> PHASE II GRO INSPECTION PHASE, III/FINAL INSPEC N <br /> INSPECTION BY DATE INSPECTION BY E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 19 <br />