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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazel tofr*A <br /> vee.:, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — fes-/tr� <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED bate Issued 6-7� <br /> (Complete In Triplicate) <br /> Application is hereby,made _t'o 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 -an'd the Rules and Regulations of the San Joaquin Local Health District: <br /> s • <br /> JOB ADDRESS/LOCATION `7 r CENSUS TRACT _ <br /> � <br /> Owner's Name 9F ✓to r. `_ Phone <br /> Address 80 10 L�.. City <br /> Contractor's NameLicense 11 Phone <br /> z�zt <br /> TYPE OF WORK Check) ; ! <br /> { NEW WELL /I� DEEPEN /? RECONDITION /_7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other,j / — <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 I Cable Tool Dia. of Well Excavation <br /> -&7� Domestic/private ,j Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing V <br /> Irrigation g �-� Gravel Pack Depth of Grout Seal <br /> Other I - Rotary Type of Grout <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; _ � <br /> State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withi 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 ue to the best of-my knowledg and belief. <br /> SIGNED r <br /> _ TITLE <br /> '(DRAW P PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASA j4IIFINAL INSPECTION <br /> INSPECTION BY -/- DATE 7—j9<©_ INSPECTION BY DATE -7e" <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M 4 <br />