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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF1,ICE USE: 1601 E. Hazelton Ave."— Stockton, Calif <br /> Telephone: 'x (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No.�3- /O <br /> THIS PERMIT EXPIRES l'=YEARtFROM DATE "ISSUED Date Is"suede�Z-73 <br /> (Complete Inv Triplicate) ` <br /> Applicationiis :hereby-madextolthe 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 andtthe'^Rul s-)and'Regulations of- the San- Joaquin Local Health District. <br /> 9317 '`71--, . j2 r CENSUS TRACT ' <br /> JOB. ADDRESS/LOCATION <br /> r• ;. Phone <br /> Owner's Name - ' " <br /> t city . :411 <br /> Address <br /> - ` License # Phone " F "T <br /> Contractor's Name , <br />?TYPE OF WORK {Check) ; NEW WELL "/ / DEEPEN / RECONDITION /7 DESTRUCTION /�T <br /> PUMP "INSTALLATION "/' / PUMP REPAIR "/>PUMP REPLACEMENT /—T i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC�TANK f.{ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P.IT. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> . <br /> of Well Casing �1 <br /> Domestic/private Drilled Dia. <br /> Casin <br /> Domestic/public Driven Gauge g a <br /> irrigation Gravel Pack Depth of Grout Seal <br /> ! Rotary Type of Grout <br /> Other <br /> Other Other Information" <br /> PUMP INSTALLATION: Contractor H.P. <br /> I Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> --7/,State Work Done <br /> PUMP REPAIR: <br /> Approximate Depth <br /> E_STRU <br /> CTION--OF WELL: Well tDiameter <br /> �. .. <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> �• <br /> YS <br /> and the State of California pertaining to'•-or regulating well construction. Within FIFTEEN DA <br /> ' after completion of my workon a new well, I will furnish the San Joaquin Local Health District a <br /> ore pu <br /> WELL DRILLERS REPORT tooft�eebeetlofand <br /> notify <br /> them <br /> nd€belief. <br /> tting the well in use. The above <br /> informati is trueF <br /> i r <br /> . TITLE _ <br /> SIGNED <br /> w� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> f. FOR DEPARTMENT USE ONLY <br /> } PHASE I , DATE <br /> APPLICATION ACCEPTED BY %r <br /> ADDITIONAL COMMENTS: �'i Pte, / INAL INSPECTION <br /> PHASE II UNS 0 INSPECTION BY DATE - <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND .FINAL INSPECTION4/72 1M <br /> 4 <br /> E H 1426 <br />