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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 07"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ?3 <br /> $� (Complete In Triplicate) <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION7 i� r.,J2041,1 R . CENSUS TRACT <br /> Owner's Name Phone <br /> ,t <br /> Address' <br /> G City <br /> Contractor's Name <br /> License #/&--2,W Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/- RECONDITION / / DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION PLW REPAIR '/C;4—PUMP REPLACEMENT /—T <br /> Other'-f-/ <br /> — 6 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> If INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ► I Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> - � Irrigation Gravel Pack Depth of Grout Sea] -•_,__,._. <br /> Other it Rotary Type. of Grout <br /> I Other Other Information ' <br /> 1� <br /> PUMP INSTALLATION: Contractor ` <br /> Type•yof Pump - C-1— <br /> PUMP REPLACEMENT: / / `State Work Done <br /> PUMP, UPAIR: State Work Donei ' 1. Qr* dV 1�I�11l ' <br /> .DF<zTRUCTION OF WELL: Well Diameter -- - T 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 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 'raell. and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and. belief. <br /> SIGNED s� ITLE <br /> (Da7VLOT3ffXN ON REV RSE SIDE) <br /> FOR DEPARTMENT .USE ONLY - <br /> PHASE I (_ <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS; t <br /> t PRASE II GROUT 'INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY MATE INSPECTION BY DATE <br /> -CALL FOR A GROUT INSPECTION PRIOR TO GROUTING-AND FINAL INSPECTI . <br /> E .H 1426 /7�twr <br />