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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> p 61'IICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �- APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. Z-//- <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) A-711"N= 0.5-/ --7�o -O/ <br /> Application is hereby made to the San Joaquin Local Health District fbr a permit to construct <br /> and,/or install the work herein described. ' This application is made in compliance with Sart Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS ILOCATION C, /f- a CENSUS TRACT <br /> Owner's Name0 L 41 L -T Phone 3 6!2-c�S'7�E <br /> Address VC .. -- City -z-a p/ L 14 e_11`- <br /> Contractor's NameIL <br /> _ License l a 6 Srf Phone u%_- <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN -/ / RECONDITION / I DESTRUCTION /? <br /> PUMP INSTALLATION jo'P11'MP REPAIR / / PUMP REPLACEMENT I� <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing "' q <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. fc7 <br /> PUMT REPLACEMENT: / / State Work Done ' <br /> PUMP 'tEPAIR: /�/ State Work Done ' <br /> ,DFRTRUCTION 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 my knowledge and belief. s <br /> I <br /> SIGNED �� � TITLE <br /> (DRAW PLOTAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I ' <br /> APPLICATION ACCEPTED -BY 0"e� DATE yl�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �490;7 DATE d <br /> I <br /> .. CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />