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C� SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR 0FICE USE: 1601 E. _ az hton Ave. , Stockton, Calif. <br /> Teleph- e:° (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> + (Complete In Triplicate) 2.03_ pY+p -0 <br />. Application is hereby made to the San Joaquin Local Health District fora 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 �ectS� ��CG�L ��D CENSUS TRACT <br /> Owner's Name t Phone <br /> Address City <br /> Contractor's Named License #��Phone ... <br /> TYPE OF WORK (Check) : NEW• WELL DEEPEN RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP_REPAIR / / PUMP REPLACEMENT <br /> Other '/—/ - --- a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY h 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ( k <br /> Industrial Casale 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 I Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor9 < <br /> Type of PUMP. ,r 1 H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done Tk.r,I,. /�� r ,aZ -- <br /> 4 <br /> hPUMP REPAIR: / / State Work Done <br /> .•JDESTRUCTION OF WELL.: Well Diameter < Approximate Depth <br /> Describe Material and Procedure <br /> Vii' { ! �., ti ' • <br /> � I hereby agree to comply- with alltlaws and regulations of the-San Joaquin Local Health District. <br /> Fand 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 m knowled a and.belief. <br /> q <br /> ► SIGNED ITLE <br /> 21 ((DW 11—LUT—PLAN ON A ARSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ille�Ilt <br /> APPLICATION ACCEPTED BY. ''' ! / �` DATE <br /> J ADDITIONAL COMMENTS: "1 <br /> PHASE II GROUT INSP.ECTTM PHASE III FI INSPECTION <br /> kINSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />