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FOR OFFICE USE: SAN JOAQUIN LOCliL H •-� <br /> EALTH DISTRICT <br /> 1601 E. <br /> Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES COmplet l yg L <br /> AR FROM DATE ISSUED , <br /> r APplicatian is hereby ma a to the San(Joaquin Local Health District for apermit Date Issle In T iplicate) ued -¢ <br /> f i <br /> e work <br /> f County Ordinanceand/or install hNo. 1862eandnthe$Rulesdan <br /> I This application is made in 'complicetwith nSan Joa uia <br /> d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> i <br /> Owner's Name CENSUS TRACT- <br /> Phone <br /> � Address �"�8� gam_ <br /> S <br /> Contractor's Name �` City <br /> License # <br /> Phone&gW_Ax <br /> TYPE OF WORK (Check): NEW WELL/ 7 DEEPEN <br /> PUMP INSTALLATION /_7 RECONDITION / 7 DESTRUCTION /-7 <br /> i <br /> Other J / /—/ P�'� REPAIR /�/- PUMP RPLACF.MENx <br /> DISTANCE TO NEAREST; SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDMER L LS PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE <br /> OF <br /> Industrial _ Cable CONSTRUCTION SPECIFICATIONS o� f <br /> Domestic/private Tool Dia. of Well Excavation <br /> /p • . Drilled Dia. of Well Casing <br /> Domestic/public Driven -� <br /> Irrigation Gauge of Casing { <br /> Other Gravel Pack Depth of Grout Seal <br /> Rotary <br /> Other Type of Grout <br /> Other Information ' <br /> I <br /> PUMP' INSTALLATION; j <br /> Contractor �„7. obo <br /> Type of Pump <br /> H.F. 's <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> /State Work Done <br /> ESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply wall laws <br /> and the State of California peand regulations of the San Joaquin Local Health District <br /> rtaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new not, I will <br /> WELL DRILLERS REPORT of the well andnotifurnish the San Joaquin Local Health District a• <br /> fy them before putting the well in use. <br /> information is true to the best of my knowledge and belief. The above <br /> SIGNEDTITLE <br /> _ <br /> (DRAWPLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> �P ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ~ <br /> PHASE II GROUT TN5PECTION P STI IN INSPECTION <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDSFINALPECT OINSPECTION. DATE .. !€ <br /> E H 1426 4 <br /> 4/72 1M <br />