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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z ° W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED ; Date Issued <br /> N{r ( j (C.omplete In Triplicate) i; <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# i( <br /> t <br /> JOB ADDRESS/LOCATIO ` CENSUS TRACT ' <br /> ��U �- <br /> Owner's Name�Li_ �a, n.� n,n. 4:i a - Phone i, <br /> Address -.. 0- City <br /> Contractor's Name License # Phone 4 <br /> } <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION '/ DESTRUCTION <br /> /-7 ;'; <br /> PUMP INSTALLATION /�/ PUMP •REPA / /IR PUMP REPLACEMENT <br /> Other <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 � I <br /> _ Industrial Cable Tool Dia. of Well Excavation F � <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casingi <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 ; <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth " <br /> Describe Material and Procedure <br /> k I hereby agree to comply with all 1 ws and regular ons 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 Distric 'a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tru to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SID I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY / -�---� <br /> ADDITIONAL COMMENTS: <br /> PHASF, TI GROUT INSPECTION I IN INSPECTION <br /> INSPECTION BY DATE S E I Y DATE <br /> CALL1FOR A GROUT INSPEC ON PRIOR TO R NG D FINAL INSPECTION. .�` <br /> E H 1426 4/72 1M <br />