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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -70 e <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7--5"-- <br /> THIS <br /> ,STHIS 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 an Regulations of the San Joaquin Local Health District. <br /> i <br /> JOS ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name /" - Phone ,-;f,3/ — 93+C� <br /> Address City <br /> Contractor's Name ' License � irAb Phone �� ^4 2�&19 q5l <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT PIV <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �U I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor " .L <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /Tr State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION 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 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 best of my knowledge and belief. <br /> SIGNED TITLE <br /> I zmzv <br /> {DRAW PLOT PLAN ON REVERSE S. E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />( APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE Ili GROUT INSPECTION P II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE66. <br /> E H 1426 7/72 1M <br />