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SAN JOAQUIN 1jS&LaEALTH DISTRICT <br /> 0 . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ��ff <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7e 21� <br /> - - - - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2`�� <br /> "I -- (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 /> JOB ADDRESS/LOCATION. 99y New-,6&a ez CENSUS TRACT <br /> Owner's Name Gc S ` d •P c Phone <br /> Address City <br /> Contractor's Nay icense (I one;���.� <br /> TYPE OF WORK (Check) : NEW WELL P-i�f DEEPEN / / RECONDITION / / DESTRUCTION J7 <br /> PUMP INSTLATION M U REP <br /> ALAIR / / PUMP REPLACEMENT /-7 Ilk <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAXK 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 d <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> t r Other Information 1114, i <br /> / <br /> PUMP INSTALLATION: Contractor A J4, <br /> i" � <br /> Type of Pump r 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 /> 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 /> information is true to the best of y kn wledge and belief. <br /> SIGNED �� ' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL. NSPECTION— <br /> INSPECTION BY DATE INSPECTION BYATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �` �"'` <br /> E .H 1426 <br />