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-"" SAN JOAQUIN LOCAL T-IEALTH DISTRICT <br /> FOR OFFICE -USL,;: 1601"E. Hazelton Ave..,< Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION=OR PUMP PERMIT Permit No. Zel _ �� jel <br /> THIS PERMIT EXPIRES 1 YEAR FIZOM DATE -ISSUED Date�Issued - <br /> (Complete <br /> ssued -(Complete In Triplicate) <br /> Application„is hereby made .to tTie 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 y Q P S �GcC CENSUS TRACT <br /> Owner's Name �O"/MJC� 10 'x (;�P�J �'� "/ F�u'�u Phone <br /> Address ` G► C uv-r City A r !/C'r !m e r e <br /> k <br /> Contractor's Name zEe-Df/G' - /,0 License i��9/'-` Phone <br /> t <br /> - --. -- <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN -RECONDITION /7 DESTRUCTION /7 <br /> i' PUMP INSTALLATION/ / PUMP REPAIR '/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well.Excavation / Z " Its <br /> Domestic/private Drilled Dia, of Well' Casing _ <br /> Domestic/public Driven Gauge of Casing a _- <br /> t Irrigation I,” Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout p_n 7�p , F' _ <br /> G Other Other Information <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump. - H.P. <br /> PUMP REPLACEMENT: / / State Work Done- ' <br /> 5 <br /> PUMP REPAIR: / / State Work Done <br /> t — <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 M'Y'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 /> I, information is tru to!' the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT 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 " " P S II/F AL INSPECTION <br /> INSPECTION BY DATE INSPECT DATE - <br /> k CALL FORA GROUT INSPECTION PRIOR ,TO GROUTING AND FINAL .INSPECTIQN <br /> t <br /> 4/72 1M <br /> E H 1426 <br />