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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73' P <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 S ,� 711 M n,( CENSUS TRACT <br /> Owners Name Phone <br /> Address9S. c�,,H ��. City <br /> Contractor's Name License # /��" Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Sb <br /> Industrial Cable Tool Dia. of Well Excavation W <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 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> r-- <br /> Type of Pump H.P. Od <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR, l State Work Done :;47,.4 ..�_.r_ _ lit <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 the best of my knowledge and belief. <br /> SIGNEDTITLE <br /> �a�t <br /> a ,,IL. �1. - <br /> (DRAW V4,OT PLAN ON REVERSE SIDE <br /> ---- FOR DEPARTMENT USE ONLY -. - <br /> PHASE I <br /> APPLICATION ACCEPTED BY - _ {" DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS N. <br /> E H 1426 7/72 1M <br />