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SAN JOAQUIN LOCAL HE,4LTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelf6n•`Aue,.; Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR-PUMP PERMIT Permit No. ZL22flLd <br /> THIS PERMIT :EXPIRES I YEAR FROM DATE ISSUED Date 'Issued <br /> (Complete In Triplicate) <br /> Application is hereby'made-to "the San Joaquin Local Health`District fo- a $ermiti 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 Sari Joaquin Local .Health District. <br /> JOB ADDRESS/LOCATION a D ' 26 ` 'CENSUS TRACT-a 040^11 . <br /> Owner's Name _ ,4 ':a', r Phone <br /> AddressCityV ^_ t <br /> �S� - BCy 5y� <br /> Contractor's Name License # Phone <br /> TYPE OF WORK Check): NEW WELL /� DEEPEN /_� RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD t CESSPOOL/SEEPAGE PIT OTHER N <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS ^ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> t Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/publicDriven Gauge of Casing -r, 16 ba- - -- <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> g � Other Other Information <br /> E <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.,P. <br />` PUMP REPLACEMENT: / / State Work Done <br /> f ' <br /> ' PUMP-REPAIR-: * ---/-.-/---State Work-Done- <br /> 1,7DESTRUCTIONOF_WELL. Well- Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> II hereby agree to comply with all laws and -regulatioris 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 Drell and notify them before putting the well in use. The above <br /> linformation is true to the best of my knowledge and belief.jSIGNED _ TITLE 024124---- <br /> (DRAW <br /> 241 4(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION,'' OytINAL INSPECTJON <br /> INSPECTION BY C� DATE INSREQTXIjON DATE <br /> CALL FOR A GROUT INSPECTIQN,..PRIOR .TO..GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />