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-Q� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. -Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -y ,) - k� -\fj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued t{ k° - ? <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/LOCATION N - I SLILZ <br /> d- CENSUS TRACT <br /> Owner's Name S 71019 Phone <br /> Address y -S T. City SZac_& _� <br /> Contractor's Name ��/.ARAI W-JU4 ♦ U C ^� License # �Zej,47, Phone <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN /_7 RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2e <br /> Domestic/private Drilled Dia, of Well Casing ZZ <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal a2 e� <br /> Other Rotary Type 'of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUGTION OF WELL: Well Diameter Approximate Depth <br /> T 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 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 my knowledge and belief. <br /> SIGNED TITLE CON TITV) C, _ <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIDN ACCEPTED BY �r DATE <br /> ADDITIONAL COMMENTS: At <br /> PHASE II GROUT INSPECTION PHA FIRAL I SPECTI N <br /> INSPECTION BY DATE INSPECTION BY ATE r4qjj_ 1 % <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />