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� i SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave', , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �a 4 =._. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ��� <br /> Application is hereb � ' (Complete In Triplicate) <br /> y ..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 J'oaquii <br /> County Ordinance No, 11662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I'�. tj <br /> CENSUS TRACT <br /> Owner's Name VIII r <br /> i Phone -� J3 <br /> Address '°� <br /> jl: City �c�C,gi�t?•t� <br /> Contractor's Name w :� <br /> �h License �d�phone <br /> TYPE OF WORK {Check): NEW WELL <br /> DEEPEN /_/ RECONDITION /_7 DESTRUCTION '/_7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR / / PUMP REPLACEMENT /l. <br /> :.Other / / --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> I` CESSPOOL/SEEPAGE, PIT • -OTHER <br /> INTENDED USE TYPE OF WELL <br /> InCONSTRUCTION SPECIFICATIONS _ <br /> i dustrial Cable Tool Dia, of Well Excavation .. <br /> Domestic/private ' DrilledU4 <br /> Domestic Dia, of Well Casing pQ <br /> i -- /Public Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> Other Rotary Depth of Grout Seal � <br /> Type of Grout <br /> I� Other Other Information ill <br /> ,ij - I <br /> PUMP INSTALLATION: I� <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> I� <br /> PUMP REPLACEMENT: State Work Done <br /> T AJ <br />-PUMP-REPAIR:_ Stat <br /> S' <br /> e--Wark-Done_: w: <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to complyl�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 i <br /> information is true to tte best of my knowledge and belief, <br /> SIGNED <br /> TITLE <br /> �� (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: Ir - DATE <br /> PHASE II GRpUT INSPECTION <br /> INSPECTION BY dh DATE r PHASE II F. N4I, INSPECTION r <br /> DATE <br /> CALL ip I'N� GTI !f , /-� <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. y <br /> E H 1426 i <br /> C72 1M <br />