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64 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0-_r.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. ��6� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue" a 75J <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 `Z 3 - 11A /k/ Al 2!�I�,-S,4C 1,'4'STRACT <br /> Owner's Name Phone _ <br /> Address <br /> '� / i4 L Y L'� -- City E.. 0 Q 1 C-A C- <br /> Contractor's Name y /�6�' ' l.V �G Q L 1 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / — -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �-Ij <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial (X Cable Tool Dia. of Well Excavation /l " <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: f / State Work Done <br /> PUMP `2EPAIR: / / State Work Done �- <br /> DRCTRUCTION 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 /> f <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 /> f <br /> SIGNED TITLE <br /> i ( <br /> PLOT PLAN ON REVERSE SIDE <br />' O DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COM14ENTS: � <br /> PHASE Ii 0 N PHASE III/FINAL INSPECTION <br /> INSPECTION B.Y. T INSPECTION BY �� - DATE -moo 1,6 <br /> E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND ,'FINAL INSPECTION. <br /> V 27 9/-hG �/7q,Mcp <br />