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SAN JOACUIN LOCAL HEALTH DISTRICT <br /> COL OIFICE USE: 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 /> (Complete In Triplicate) 9 <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 apprlicati,on 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 C0 &_L - 5 - F111-74P1119 5 CENSUS TRACT " <br /> Owner's Name ® $' p Phone <br /> AddressX d City " !9I elle t- <br /> Contractor's Name License # 1163 Phone S <br /> TYPE OF WORK (Check) : NEW WELL '//[ DEEPEN / / RECONDITION ! / DESTRUCTION <br /> PUMP INSTALLATION /_/7 PUMP REPAIR/ / PUMP REPLACEMENT' <br /> Other /_7 1 7 <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES 1 PIT PRIVY !p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL 1CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of'' Well Excavation 0`' } <br /> f/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4A 6.19J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 571 ' I <br /> Other �_ Ro tary Type of,, GroutiL�`! _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: / j State Work Done _ -- <br /> PUMP UPAIR: / / State Work Done k <br /> ,DFsTRUCTION OF WELL: Well Diameter Approximate• Depth <br /> Describe Material and Procedure ! , <br /> [ 1 <br /> I hereby agree to comply with all laws and regulations of .the San Joaquin Local' Health District <br /> and the State. of. Cali.fornia..pertain ng co•.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 he bes of my knowledge and belief. <br /> r SIGNED -- TITLE l <br /> QLAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B.Y 9. DATE` 62-a -J�/ <br />' ADDITIONAL COMM-NTS; <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION + <br /> 19SPECTION BY DATE INSPECTION BY ]TATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br />