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5` SAN JOAQUIN LOCAL HEALTH DISTRICT � �✓r! " � 3- <br /> 'OF. OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�7p1rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Stealth District. <br /> JOB ADDRESS/LOCATION �_ nJ � <br /> p��;. � CENSUS TRACT <br /> Owner's Name y ,� '�t-(,WQ Phone <br /> Address d` 9 Z2� T �/1M�1 �tz., / ' rLCity <br /> 1" <br /> Contractor's Name � r �� p � � --� � License 4y�Phone <br /> TYPE OF WORK (Cheek); NEW WELLDEEPEN j / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 <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: j / State Work Saone <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, 3 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 -- �.tt ��+1 -- TITLE __,f-]'1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P ' SE I GROUT INSPECTION PHA NAL INSPECTION <br /> INSPECTION BYDATE -\ -(B INSPECTION BY DATE fL S <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E A 1426 5/731rz <br />