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SAN AQUIN LOCAL HEALTH DISTRICT <br />Y <br />FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif., <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermiC-No: ;79-= 9 6/0 <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-/v - 7S-- <br />Complete <br />S~( <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 incompliance with San Joaquin <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION 14iod f A <br />yj ' CENSUS TRACT <br />Owner's Name Phone <br />Address City <br />Contractor's Name License # Phone <br />ry <br />TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION '/ / DESTRUCTION /_7_ <br />y <br />PUMP INSTALLATION /A4- PUMP REPAIR/ / PUMP REPLACE : NT / <br />O they' /6:f <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />b <br />F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br />Industrial Cable Tool Dia. of Well Excavation <br />Domestic/private Drilled Dia. of Well Casing <br />Domestic/public Driven Gauge of Casing v <br />1----irrigation Navel Pack Depth of Grout Seal `y1' <br />Other 11 Rotary Type of Grout <br />i Other Other Information <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />PUMP REPLACEMENT: f / State Work Done <br />f` <br />r <br />PUMP -tEPAIR• State Work Done <br />DFSTRUCTION OF WELL: Wo-11 Diameter , Approximate Depth <br />r Describe Material and Procedure. <br />y <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 an a new well., I will furnish the San Joaquin Local Health District a <br />WELL DRILLERS REPORT of the well and 'noti€y them before putting the well in use. The above f <br />information is true to the best of my knowledge and belief. <br />SIGNED c.+p TITLE <br />I 1. DRAW PLOT FLAN ON REVERSE SI E) <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />I APPLICATION ACCEPTED .BY DATE ( J <br />r <br />f ADDITIONAL" COMMENTS: 3 <br />PHASE T1 GROUT INVECTION PHA5E I/FINAL INSPECTION <br />INSPECTION BYlyj I.C6. D TE INSPECTION BY .DATE <br />CALL FOR A GROUT INSPECT N PRIOR TO GROUTING AND FINAL INSP ON. <br />E H 1426 5/731M