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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF.sOFF 'CE US -: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466--6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �13 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 �. ,� w� /p�J - L��O _ CENSUS TRACT <br /> Owner's Nam Phone <br /> <tAddress,� . � .s� � �, y Jt E /o.v� City ' <br /> Z <br /> Contractors»Name.. D, (n <br /> License # Phone <br /> - _ - - Mfr - -- -- - - - --- -, •- - - <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /TI RECONDITION Jam./ DESTRUCTION /? <br /> PUMP INSTLATION'Y/ PLW REPAIR / %' PUMP REPLACEMENT / <br /> AL <br /> Other/ <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ® PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE 'Y TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - ,-L Cable Tool Dia. of, Well Excavation ` <br /> Domestic/private Drilled Dia. of Well Casing <br /> i +• <br /> Domestic/public.- _ ... Driven—.". --.�...-,,Gauge of Casing',: r F0 _ A <br /> Irrigation . Gravel tPack >a-j Depth of Grout Seal : <br /> T Other •RotaryType of Grout <br /> Other Other Information . <br /> - <br />�fpr �`, <br /> A0144-V <br /> P� INSTALLATION: Cont char <br /> Type of Pump Uf.f H.P. ^- <br /> PUMP REPLACEMENT: / / State Work Dane F <br /> PUMP 2EPAIR: / / State. Work Done <br /> DF�TRUCTION OF WELL: Well Diameter I Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations offthe San Joaquin Local Health. District <br /> and t.he' State of .California pertaining to or regulating well 'canstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will _furnishlthe San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the and notify them before putting the well in use. The above <br /> information 's true-to-the es.t `o �owledge and belief. <br /> SICNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED . Y s � DATE �3 <br /> ADDITIONAL COMMENTS <br /> PHAS I GROUT. INSPECTION PHASE IjjINAL INSPECTiO <br /> INSPECTION BY DATE 6-j INSPECTION BY DATE <br /> -- CAI.L- I'OR A-GROUT-INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> xr t �. 5/731-M <br />