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. ., � <br /> 7r- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r <br /> (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 X45Z Al, CENSUS TRACT <br /> SF¢OFNW f¢OF • <br /> Owner's Name Phone _759- <br /> Address <br /> S - 3. <br /> Address O O D.3 City GGEit/lEA/T�� <br /> Contractor's Name _.ELS_._..,4, G/B.SD/�/ T� License Phone Z 3¢ 8 <br /> TYPE OF WORK (Check) : NEW WELL /-VT'DEEPEN /_7 RECONDITION /% DESTRUCTION /"7 <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS ®-*SEWER LINES DO ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> 6 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation _(�"�-oD�- fO�� r�ff. � <br /> v Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing <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 PumpR WE ! 5AWe H.P. — D <br /> ' 4 <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 my knowledge and belief. <br /> �� k <br /> SIGNED 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 III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1 DATE <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />