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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> €'OI.:OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <br /> k THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued 2__4i-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. * This application is made in compliance with San Joaquin <br /> f County Ordinance -No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION = - NSUS TRACT <br /> f 1 <br /> Owner's Name �. `? �'P^ •7[J7/Yl/P[Jt- _ Phone <br /> Address <br /> City ' <br /> Contractor's Name VPJIAQ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN './_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK / , SEWER LINES PIT PRIVY ^4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation " j <br /> Domestic/private I Drilled Dia. of Well Casing ov <br /> Domestic/public 1 Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Other 1 ✓ Rotary Type of Grout <br /> Other Other Information .�E - <br /> PUMP INSTALLATION: Contractor <br /> Type of PUMP H.P. <br /> PUMP -REPLACEMENT: j_/ - State-Work-.Done :;- —. <br /> PUMP UPAIR: / / State Work Done <br /> ,DFGTRUCTION 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 bn a new well, I will furnish the San Joaquin Local Health District al <br /> 14ELL 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 /> a. �SIGNED ' TITLE <br /> (D PLO PL ON REVERSE SIDE) <br /> FO TMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCE DATE `�Z- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II±I/ INAL_INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY`,�' ',, .-� DATE 4® <br /> � L YOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � { <br /> -E fl-,1426 C /?'a F <br />