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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr..'OFF ICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> + Telephone: (209) 466,-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� 1D <br /> 'THIS PERMIT EXPIRES 1 YEAR .FROM.DATE ISSUED Date Issued S:/ecu <br /> (Complete In Triplicate) ; <br /> Application is hereby made to the San Joaquin •Local. Health .District for a permit totconstruct <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/LOCAT10y.(, I G <br /> CENSUS .TRACT <br /> Phone <br /> Owner's Name r=9 <br /> Address' '- d City <br /> (� License # ��,, Phone <br /> Contractor's:.Name �.]�h) <br /> TYPE OF WORK (Cheek} : - .NEW WELL /-7 DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTLATION / LTN� REPAIR / PUMP REPLACEMENT / T <br /> ALC <br /> Other ./ / C> <br /> DISTANCE TO NEAREST:` SEPTIC TANK SEWER LINES PIT PRIVX <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .t 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 /> I Other, Other Information <br /> PUMP INSTALLATION: ^ContractorAga <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR• /F State Work Done <br /> DFgTRUCTION OF WELL. '" Well 'Diameter Approximate Depth <br /> n, Describe Material. and'Procedure <br /> s - <br /> I hereby agree ­to comply with all lags and regulations of the San Joaquin Local Health District <br /> r and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I1will furnish the San Joaquin Local Health District a <br /> 1 WELL DRILLERS-REPORT`of .the well and notify them before putting the well in use. The above <br /> information is true to the t of •y ale e.and belief. <br /> / y TITLE _ Alts r-. <br /> 5 SIGN , . <br /> (D OT PLAN.O VERSE SIDE} <br /> 0 <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1----2_V_ <br /> ti <br /> CALL-F'OR-A GROUT- INSPECTION PRIOR TO-..GROUTING AND .FINAL INSPECTION. �,- <br /> .. . . •.. - 5/73 IN <br /> ti <br /> 77 IT 7 -- <br />