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�JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3r p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued i,2.75� <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 :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION 13 d :7 '1 ��C/ a4,,' CENSUS TRACT <br /> Owner's Name ►/y!�_ _ Phone <br /> Address Z? D 7 _ City <br /> License # 2(-,5-- Phone G k <br /> Contractor's Name � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION / / DESTRUCTION /7 <br /> PUMPAL <br /> INSTALLATION /_1 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K 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 d <br /> Domestic/private Drilled Dia. of Well Casing V <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: '.d.' State Work Done <br /> PUMP `tEPAIR: / / 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 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. A- <br /> SIGNED <br /> TITLE e <br /> - (DM'PLOTzfXA9 ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONL <br /> PHASE I <br /> APPLICATION ACCEPTED BY v / DATE -� <br /> ADDITIONAL COMMENTS: Z?� <br /> PHASE II GROUT INSPECTION PHASEUI/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 5/=l3 <br />