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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF, OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7__27_7S_ <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 �.��73 I�d7 P /CA' ��C ��1 - —_ CENSUS TRACT <br /> Owner's Namein <br /> .a-e4 - Phone 1-TIX a/OLE <br /> Address �S"77 6x1 X1' - - - — City _4ced n <br /> Contractor's Name ��t/fA�e(! � i License #.I L114L Phone <br /> TYPE OF WORK (Check) : NEW WELL /—/ DEEPEN I_% RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR /—/—PUMP 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 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor w! - <br /> Type of Pump _Swh, ---,.. H.P. `x. .. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> E DFRTRUCTION 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 /> f <br /> SIGNED _�.��.2� _ _ TITLE 7- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED BY ° � �' , DATE / � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4g 42Wj, DATE .G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/'731M <br />