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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F't7F..OFTICE 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 S � <br /> (Complete In Triplicate) 0 gtr_ E.30_O �- <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 Joaquip. <br /> County Ordinance No. 1862 and the Rules d_Regulations of the San Joaquin Local. Health District.I <br /> JOB ADDRESS/LOCATION tov- ` 1/�acif a�!r „�_. toe' CENSUS TRACT - <br /> Owner's <br /> RACT -Owner's Name 'To CA,W, P. ` °�, Phone j q g p <br /> Address p 1 <br /> City pvt_ r <br /> f� f <br /> Contractor's Name License # /(yo?,�T,� Phone <br /> 53 <br /> J TYPE OF WORK (Check) : NEW WELL g/r DEEPEN '/—/ RECONDITION 'DESTRUCTION <br /> PUMP, INSTALLATION /% PUMP REPAIR PUMP REPLACEMENT /� 1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � ~PIT PRIVY � <br /> } SEWAGE DISPO'SAL' FIELD --- -CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSi <br /> Industrial Cable Tool` Dia. of Well Excavation la"., 7 <br /> s.Domestic/private Drilled Dia. of Well Casing J 901 Y + <br /> D6mestic/public Driven Gauge of Casing <br /> Irrigation `Gravel ; ack Depth of Grout Seal <br /> Other ,y ` Rotary Type of Grout C e <br /> Other Other Information J <br /> r <br /> PUMP INSTALLATION: Contractor - A M E <br /> r Type of PumpL.0i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: jam/ State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter n G Approximate Depth ` <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District � <br /> and the S?tate2oCalifowrnia pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after comm ork on a new well., I willfurnish the San Joaquin Local Health District a 4 <br /> WELT, DRILT o the veli an o ify them before putting the well in use. The above <br /> informati t my owledge and belief. ' <br /> SIGNED TITLE <br /> (DRA14 PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE S <br /> ADDITIONAL COMMENTS: <br /> P E II GROUT INSPECTIO - PNPECT O <br /> INSPECTION BY DATE cINSPECTION TE A A <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. , <br /> 7 u 1411 <br />