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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:OFFICE 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 �. <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to consta:uct <br /> and/or install the work herein described. , This application is made in, compliance with San Joaquin <br />�Cou V Ordinance o.�862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> V ,'fs e",T+r EI�s t97'ary� r[r�sl� 'c/,o� •� 44t <br /> JOB ADDRESS/LOCATIO , a1 t A/1' CENSUS TRACT <br /> Owner's Name 111V 6Z:Z-Leat7 PhoneZI& <br /> Address <br />�. �i S � City <br /> ty <br /> Contractor s Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL/_/ DEEPEN ./7 RECONDITION / / DESTRUCTION / 7 <br /> AL <br /> PUMP INSTLATION REPAIR/ / PUMP REPLACEMENT /7 <br /> O-ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' O <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER SIIII <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well CasingF <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary a Type of Grout <br /> Other - Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done f <br /> PUMP `ZUPAIR: / / State Work Done •--•+.+»..... <br /> ,DFCTRUCTION OF WELL: Well. Diameter .__ _ Approximate Depth <br /> Describe Material and Procedure <br /> 4 <br /> I hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the State of lifornia pertaining to or regulating well '-construction. Within FIFTEEN DAYS 4 <br /> after compl on of my rk on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL �RS REPO o well and notify them before putting the well in use. The above <br /> informa on is est of my knowledge and belief. <br /> SIGNE , TITLES `r! '�--~'_ <br /> (DRAW PLOT PLAN ON REVERSE SI ). <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION CCEPTED .BY DATE <br /> ADDITIONAL OMMENTS: <br /> PHASE II GROUT IN91PECTION PHASE I:1j/FII9AL I19SPEC;TI <br /> INSPECTION .BY DATE INSPECTION BY DATE <br /> CALL TOR A GROUT INSPECTION PRIOR T0• GROUTING AND FINAL INSPECTI . <br /> E H 1426 1� /71 <br />