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/_ <br /> , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE__ SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> THIS PERMIT` EXPIRES i YEAR FROM DATE ISSUED II' .ate ssued <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 E CENSUS .TRACT <br /> Owner's Name <br /> 'v4 Phone <br /> Address '� J / �. •L,1Zi/1 U—'- City <br /> Contractor's Name `"LGttlL�i- �. <br /> License ��jll�7� fi� fi Phone <br /> TYPE OF WORK (Check): NEW WELL U-7 DEEPEN /% RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other,1/ / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of Well Excavation <br /> /Domestic/private t -i- Drilled Dia, of Well Casing <br /> Domestic/public _F Driven Gauge of Casing <br /> Irrigation J Gravel Pack Depth of Grout Seal <br /> Other I /--Rotary Type of Grout <br /> a <br /> t Other _ Other Information p� <br /> PUMP INSTALLATION: Contractor <br /> Type Of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP-REPAY-R: -'—/-/—State-Work Done- . _ <br /> ETRUCTION OF : Well Diameter <br /> -� SWELL <br /> _ Approximate Depth <br /> Describe Material and Procedure <br /> J <br /> I hereby agree to comply withlall 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 /> I <br /> SIGNED Rf y TITLE . . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FO EPAgR�UT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP DATE ,-7� _ <br /> ADDITIONAL COMMENTS: <br /> PHASE I AROUT INSPECTIO F IIIyF/t4AL INSPECTION <br /> INSPECTION BY DATE INSPE TION B DATE <br /> CALL FOR A GROUT INSPECTION..PRIOR. TO GROUTING. AND FINAL INSPECTION. <br /> E H 142£ 7/72 1M <br /> I <br />