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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601+E. Hazelton 'Ave.';}-Stockton, Calif. <br /> Telephone: (209):i!466"6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. U" <br /> THIS PERMIT EXPIRES 1 YEAR'FROM DATE `ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatioril,is.hereby;madeito the San-Joaquin.- Local Health District fora;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 andtthe Rulesfand Regulations--of.-the San Joaquin Local Health District. <br /> t R"Z g' -., - . . _ r: - �r►-�,.J-' r 7q •-. /7 i- �3 <br /> JOB ADDRESS/LOCATION C , 1V ,. CENSUS TRACT, <br /> Owner's ,Name�..S 3 f <br /> od: -Phone'. <br /> Address / ,/. G City r 7101/ <br /> Contractor's Name ��� ,� .� License # <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �J SEWER LINES PIT PRIVY z ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation r Or <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casingn <br /> Irrigation r Gravel Pack Depth of Grout Seal 12 <br /> Other Rotary Type of Grout <br /> S <br /> Other Other Information <br /> PUMP INSTALLATION:, ,.,- Contractor W A_711 <br /> ` Type of Pump S Q S H.P. / <br /> PUMP REPLACEMENT' <br /> State Work Done'-""" <br /> PUMP REPAIR: / / State Work Done <br /> ,2ESTRUCTION OF WELL;= Well Diameter Approximate Depth <br /> Describe Material and Procedure (' v <br /> I hereby agree to Cy <br /> with all laws a d regulations of the San Joaquin Local Health District <br /> and the State of Ca ifornia pertaining tc or regulating well construction.' Within FIFTEEN DAYS <br /> after completion of work on a new well, I will furnish the San Joaquin Vocal Health' District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well=in -use. ; ;The above t <br /> information true. o' he best of my knowledge and belief. ±j ` ' ry <br /> SIGNED - <br /> TITLE- 1V V 9_4 - <br /> € (DRAW PLOT PLAN ON REVERSEiSIDE) I <br /> FOR DEPARTMENT USE ONLY <br />--PHASE I ,_.....���...�.........- - -- <br /> APPLICATION ACCEPTED BY V ._ DATE i ' <br /> ADDITIONAL COMMENTS; , 7) <br /> �-f PHASE II GROUT II4SPECTION .1"."PHAS 1II/Fr INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H' 1426 ... 4/ 2 1M <br />