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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,- Z5- P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued cj-2 7 y <br /> (Complete In Triplicate) <br /> Application is here y 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 p a CENSUS TRACT S <br /> Owner's Name ,y �- <br /> Phone ,3 S <br /> Address / a, &114 121 <br /> City <br /> Contractor's Name . License 4E4.2,3 � Phone ' <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /? RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /)� <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 WELT. A <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> Other Rotary Depth of Grout Seal <' <br /> Type of Grout <br /> ._ ---- - Other Other Information O <br /> P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 0 44, eta,) <br />. PUMP REPAIR: <br /> / / Stake Work Done _ <br /> } <br /> .2ESTRUCTION 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 /> SIGNED .�, ' .� R 4 . TITLE 1 <br /> (DRAWPLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: 4*1=6— <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. F <br /> L H 1426 7/72 1M <br />