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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOT"OFF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,( � <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued >=,29-7c,G <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 Sate Joaquin <br /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> Z, CENSUS TRACT <br /> JOB ADDRESS/LOCATION %7 �D� C. <br />} <br /> Owner's Name /3 L I// Phone <br /> Address �77 -/6 32 -7 �-N N�4 N T 847 City ' <br /> Contractor's Name <br /> License #7.Gs 7GL_ Phone iVf,6r 9222 - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ /` RECONDITION / / DESTRUCTION r7 <br /> PUMP INSTALLATION PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other / / <br /> c DISTANCE TO NEAREST: SEPTIC TANK ryto SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' _ X. Cable Tool Ilia. of Well Excavation ice" p� <br /> Domestic/private Drilled Dia. of Well Casing V <br /> ! Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal U` <br /> Other Rotary Type. of Grout G � <br /> ---- Other Other Information : <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.., ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_qPAIR: % 1 State Work Done"' <br /> ,DF-,TRUCTION OF WELL: Wel]. 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 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 /> 4 <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 my knowledge and belief-. - " - <br /> `SIGNED "� -(DRAW VMT PLAN ON REVERSE SIDE) r <br /> ' FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED ,BY ' . DATE l Z� <br /> r` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 W IL9 5/731M., __.. <br />