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a /S3o L t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT `-^•� YJ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> . (Complete In Triplicate) Dr,-s -. 12z o 3 <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. 186& and.the Rules and., Regulations of the Sari Joaquin Local` Health District. <br /> JOB ADDRESS/LOCAT e�%O, 'ev do— L"o <br /> 41 <br /> CENSUS TRACT <br /> Owner's Name 7- ►' Phone <br /> Address d. City . j <br /> Contractor's Name icense #a-��Phone -- <br /> r <br /> TYPE-OF`WORK' (Check); NEW WELL / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /7 -- <br /> PUMP INSTDATION / / PUMP REPAIR PUMP REPLACEMENT �I <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK lySE INES PIT PRIVY <br /> SEWAGE DISP16Xr FrELDCRKWOO t1SEEPAGE PIT OTHER [� <br /> INTENDED USE TYP OF WELL CONSTRUCTION SPECIE IONS <br /> Industrial X Cable Tool Dia, of Well Excavation <br /> - Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C/ —r-4 <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 *30 <br /> PUMP REPAIR: / / State Work Done <br /> P)gSTR1ICTION 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 /> informatio s true o t st of my knowledge and belief. <br /> SIGNED A <br /> TITLE Q <br /> RAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 14 <br /> ----- <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION-- <br /> INSPECTION <br /> NSPECTION'INSPECTION BY DATE INSPECTION BY , ,:X DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H.1426 7/72 1M <br />