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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T07 OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION Olt PUME, PERMIT Permit No. �3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> ii (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 /> i <br /> JOB ADDRESS/LOCATION r Q O �✓ JCENSUS TRACT <br /> Owner's Name . •p� '� Phone <br /> Addressp U BGL City ' /' 'el <br /> / i <br /> Contractor's Nasse / License # Phone ,L <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/-/ RECONDITION '/—/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR .& PUMP REPLACEMENT /7 <br /> Otherp/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPQOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r Cable Tool Dia.`-of Well Excavation- � <br /> Domestic/private i Drilled . Dia. of Well Casing v <br /> Domestic/public t Driven ' . Gauge of Casing O k <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Confr�ictor . S�ij c <br /> Type of Pump -- :is Y' J� (! _HP. __ <br /> — <br /> PUMP REPLACEMENT: / "/, State',Work Done <br /> PUMP '2EPAIR: -State Work Done ' <br /> i i <br /> ,DF.RTRUCTION 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 Jo quin Local Health District <br /> and the State of California pertaining to or regulating well ''consttion. 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 /> informati.on_i&,true to the best of my kno ledge and -belief. <br /> SSIGNED �� . . ! L A;TYLE <br /> (DRAW PLOT-P-LONRE SE SIRE) <br /> `Fft DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED .B DATE 73 <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY -.DATE INSPECTION BY ATE <br /> ..CALL FOR A GROUT INSPECTION PRIOR TO..GROUTING,AND FINAL I 0 <br /> E H 1426 r�171 vu <br />