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` �lw SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR IFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif, <br /> #� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��4,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued./�?-7:7,3 <br /> (Complete In Triplicate) ZO 3 -- 8- 'o c7.7 j <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 /> 56 <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br /> Owner's Name <br /> Phone 9rA <br /> Address �' City ell <br /> LZ <br /> Contractor's Name License 4� <br /> � „2�7.z � Phone <br /> TYPE OF WORK (Check) : NEW WELL 1,!�/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other L-1 a4iaa42 , <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 N <br /> Domestic/public Driven Gauge of Casing <br /> __X_ _ 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. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <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. r <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE �. r <br /> ADDITIONAL COMMENTS- <br /> PHASE <br /> � <br /> PHASE II GROU INSPECTIO PHASE AIIJFINAL INSPECTION 4 <br /> INSPECTION BY DATE INSPECTION BY DATE 3-3 -7-S <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. j <br /> E H 1426 7/72 1M <br />