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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. . i <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <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 construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1852 and'tlie` Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO NW �-/��/� �1J ��lC� '� CENSUS TRACT _ <br /> Owner's Nam r .., s cy.. . Phone 4 Soa <br /> Address (� ��C�llfN �a- `��.�� �` ,. City . <br /> Contractor's Name _�u ,1.�_ �,t License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION { / PUMP REPAIR /. T PUMP REPLACEMENT /_7 <br /> Other <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 W <br /> T---7Domestic/private Drilled Dia, of Well Casing q ' <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 5 <br /> PUMP INSTALLATION: Contractor ..�^ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR-: — -- /X/-_Stato Work Done- <br /> 'rye <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 z. <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE t <br /> (DRAW PLL . PLAN ON REVERSE SIDE) - - <br /> --- FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY % � G�� �+ � DATE i 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HA III FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Q Z <br /> CALL FOR A GROUT..INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI f <br /> E H 1426 7/72 1M <br />