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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7OI,�OFrICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 '4 <br /> AP�I ;; <br /> CATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Gr %T.36,P <br /> THIS PERMIT EXPIRES 1 IkEAR FROM DATE 'ISSUED Date Issued 6 <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 ° CENSUS TRACT <br /> Owner's Name � .�'�'�-- � Phone <br /> Address 4' se City <br /> Contractor's Name6e+- d—X License #0)4'071W Phone,` <br /> TYPE1OF WORK (Check): NEW WELL ',K_/ DEEP N�/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP -INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / -- — <br /> T-DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> € /SEWAGt DISPOSAL FIELD CESSPOOLJ SEEPAGE PIT OTHER .,-,,__ <br /> .,I_.INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial 1 .._ Cab 1e'.-Toa_l ,_— ;7 Dia:-`of We:11` Excavation C-- <br /> Domestic/private 1 Drilled Dia. of Well Casing ^ tom ~ <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 <br /> PUMP° INSTALLATION: Contractor I <br /> Type of Pump i H.P. <br /> PUMA.' REPLACEMENT: ] / State Work Done*,. <br /> PUMP 'tEPAIR: / / . State Work Done__ <br /> PPSTRUCTION OF WELL: Well Diameter ; Approximate Depth <br /> Describe Material and.Procedure <br /> f 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 "constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well., -I-will7furriish -the San Joaquin Local Health District a <br /> [BELL' DRILLEi�S REPORT of the well and -notify them before putting the well in use. The above <br /> informatia Ais�true to the best of my' krRjowledge .and_.belief:_ <br /> i SIGNED ' ' P 'TITLE l <br /> lI <br /> - (DRAW PLOT PLAN ON -REVERSE SIDE) <br /> I f FOR DEPARTMENT USE ONLY' <br /> PHASE I _ r <br /> 4 <br /> APPLICATION' ACCEPTED BY A <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUTJINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY }DATE INSPECTION BY DATE /=.z.o J.? <br /> CALL FOR A GROUT INSPECTION PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> F. N 1426 r�/71im <br />