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_ YY SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :7 3 - qq <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - C-- 3 <br /> (Complete In Triplicate) <br /> Application is hereby made. to the San Joaquin Local Health District for a permit to const-:uct <br /> and/or install. the. work herein described. ' This application is made in compliance with Sats Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District, <br /> JOB ADDRESS/LOCATION r-5-.:L SL ��y���' CENSUS TRACT , <br /> Owner's Name Phone <br /> Address _� S1A q:2 AIA City <br /> Contractor's Name c99License # 3y Phone 7--7` <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/T/ RECONDITION /—/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 <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 ,0 <br /> PUMP "kEPAIR: / / 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 California pertaining to or regulating we11 '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 /> WE w in use. The above <br /> WELL DRILLERS REPORT of the well and notify thew before putting the well <br /> information is true to the best of know ed e-a d belief. <br /> j SIGNED ® ITLE <br /> iZj D W PLOT PLAN ON RtWERSE SIDE)- <br /> t v FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .$Y DATE :/,--.5 <br /> ADDITIONAL COMMENTS: <br /> PI4ASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY - DATE - INSPECTION BY DATE <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - - , .„1 rG /7z u <br />