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SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. >2_1/_35p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,,72-,7-3 # <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/LOCATION ; 7 7 L'L4 _- CENSUS TRACT <br /> Owner's Nam Phone <br /> Address _ ��7 �,n1 ��� _ - -- cityf„- <br /> Contractors Name / "> �,. _ __g. � ,� �, ) -- - _-- License # jePS7.. _ Phone L5 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR Z/ PUMP REPLACEMENT /- <br /> Other <br /> , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <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 p <br /> PUMP REPAIR: /bC/ State Work Done <br /> .RESTRUCTION 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 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 /> SIGNEDTITLE / <br /> i (DRAW PLOT LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY DATEZ 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> '. E H 1426 7/72 1M <br />