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SAN JOAQUIN LOCAL HEALTH DISTRICT }� <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , .Stockton, Calif. Iff <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 <br /> Z'� y J <br /> -J .© (Complete In Triplicate) _ J <br /> Applicat�f�ion is hereby- <br /> made to the San Joaquin Local Health District for 'a permit o r construct <br />{ anal/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 />' JOS ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name .� � ✓� - <br /> Phone <br /> Address Q 1k 4 <br /> City <br /> Contractor's Name <br /> License # �hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /jr/ <br /> Other PUMP REPLACEMENT /_7/ / — _ =�' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ► <br /> Other 4 Rotary Type, of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f <br /> H.P. �- <br /> PUMP REPLACEMENT: <br /> / / State Work bone <br /> PUMP REPAIR: <br /> State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 owl eran- belief., <br /> t <br /> SIGNED <br /> I- <br /> { W PLAN ON R RSE SID–Ey-- <br /> FOR <br /> PHASE I <br /> DEPARTMENT USE ONLY <br /> APPLICATIONTION ACCEPTED BY <br /> ADDITIONAL COMMENTS: +. DATE 2.2 2�:;"r <br /> PHASE 'II GROUT INSPECTION <br /> INSPECTION BYPHASE II FINAL INSPECTION <br /> DATE INSPECTION BY DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT14. +� <br /> E H 1426 <br /> 7/72 1M <br />