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v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .6—T. OFF ICL USE-. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zig_2 gfl <br /> 7Lf - X33 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ( _ <br /> (Complete In Triplicate) <br /> Application is hereby spade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worst herein described. * This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the�Rules and Regulations <br /> --ofthe San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION SSS` !I/ r QGcJ�.s" 7a I�►es. e ./. G �. SUS TRACT <br /> Owner's Name Phone�G,f-- 17'` 70 <br /> Address _ -.Q 7.�a1 ....__ �L/ o�e t,*,e � Cit Q T <br /> Contractor's Name /VGi -�. / License Phone � � <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN /_7 RECONDITION _f_1 -DESTRUCTION/-7 <br /> PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAI4K EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER D <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Ot:her -jam_ Rotary Type of Grout <br /> Other Other Information (` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4% H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Yaws 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: <br /> WELL DRILLERS REPORT of th well and notify them before putting the well in use. The above <br /> information is true thlbest of my knowledge and belief. <br /> SIGNED _ TITLE eg6e� <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,f <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE., I/FINAL INSPECTION <br /> INSPECTION BY ` DATE INSPECTION BY DATE <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/7319 <br />