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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR _OFFICE SE: /1601 E. Hazelton Ave. ; •StoQkton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;PZ ��/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,/ 7a . <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/LOCATIONCENSUS TRACT <br /> Owner's Name r,o :jt. •4f,F_- 'Phone <br /> AddressL1?VCt_ J" :1.rcA ..lUI City <br /> Contractor's Name _ c nse ���`�`� »Phone 33©QZ— <br /> _J. <br /> TYPE OF WORK (Check) : NEW WELL / DEE /_/ COND IO / DESTRUCTION /? <br /> PUMP INSTALLATI / P PAI _/ PUMP REPLACEMENT I- T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIOTANK t LINE PIT PRIVY <br /> i SEWAGE �SPOS IE C §SPOOL/SEEPAGE PIT OTHER E; <br /> INTENDED USE TYP OF EL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab ` Tool Dia. of Well Excavation <br /> Domestic/private Drilled a. of Well Casing 1� <br /> Domestic/public riven Gauge of Casing /D <br /> Irrigation ravel Pac Depth of Grout Sear <br /> Other tart' Type of Grout !� <br /> her Other Information " <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Stat or ne <br /> PUMP REPAIR: / / State r one <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> iin€ormation is true to-the best of my knowledge and belief. <br /> SIGNED <br /> O'N' 9,2,ri,, '� ,. 'TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ACCEPTED BY <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION MSE III FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECT.ION.PRIOR_ TO GROUTING AND FINAL INSPECTION.' <br /> E H 1426 7172 1M <br />