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/! 1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USL:: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,s,),981d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;7- 7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> axed/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 16 9 CENSUS TRACT <br /> Owner's Name Phone <br /> Address '/j� /}-( �,�p� ,/]�y�L �� City <br /> Contractor's Name License Y4,&.j.F�Phoneg <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN '/—/ RECONDITION /—/ DESTRUCTION 17 _ <br /> PUMP INSTALLATION /—/ PLW REPAIR / / PiIMi' REPLACEMENT /-T W <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 �x 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 <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DF-,TRUCTION 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 />,j information is true to the best of my knowledge and belief. <br /> SIGNED TITLE _dl <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��� <br /> ADDITIONAL COMMENTS: <br /> R GROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 ��. - - - -- -_ 51731M <br />