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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) - 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z_ j-P <br /> s Date Issued �-_3 73 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED' .--�-- <br /> T- <br /> (Complete 3n Triplicate)�r - ?S0 -/� <br /> o cOTL <br /> Application is hereby made to;taeesSanb JoaquinLoapplicati°n is made inco compliancea permit with San Joaquin <br /> 1 Health District-for <br /> Joaquin ¢ <br /> ied. his <br /> and/or install the work herein <br /> 18b and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. nd,the Rules <br /> CENSUS TRACT -s i <br /> JOB ADDRESS/LOCATIONY <br /> c Phone <br /> Owner's Name: <br /> City <br /> Address - J <br /> License # Phone <br /> Contractor's Name <br /> t <br />` DEEPEN '/ / RECONDITION /_7 DESTRUCTION IT <br /> TYPE OF WORK (Check) : NEW WELL / / D r <br /> PUMP INSTALLATION J / PUMP`REPAIR / / PUMP REPLACEMENT <br /> Other <br /> } SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEiPAGE PIT- <br /> SEWAGE <br /> IT, OTHER <br /> SEWAGEDISPOSAL PTEA} /� <br /> tf <br /> U,j0 �� l r CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE E OF WELL I ' <br /> jIndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Drilled Dia.. of Well Casing <br /> � Driven Gauge of Casing <br /> Domestic/public <br /> � Irrigation Gravel Pack ,Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other <br /> Other Other Information <br /> ir FF <br /> Qy - .CJS <br /> PUMP INSTALLATION: Contractor H,P, <br /> i <br /> Type.;of Pump v_ <br /> } PUMP REPLACEMENT: State Work Done <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> .: Approximate Depth <br /> DESTRUCTION OF WELL;.. WellaDiameter <br /> Describe_Material _and _Pzocedure , - <br /> i <br /> ' y with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to compl <br /> and the State of California pertained of will furngshethecSan tJoaquin Local HealtDistrict a <br /> after completion of my work on a new , <br /> otify them before putting .the '`,7ell in use.. The above <br /> WELL DRILLERS REPORT of the well and n <br /> information is true to the best/,of my knowledge and belief. <br /> TITLE <br /> SIGNED tD.� PLOT PLAN ON REVERSE SIDE) <br /> . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> I APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY /' DATE <br /> INSPECTION BY A DATE - <br /> °. CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />