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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7i/- ,23 SA <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> / S7s i E Ty-Zd (Complete In Triplicate) /0 o0?- 0'70 - o/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constluct <br /> and/or install the work herein described. This application is made in compliance with San Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District J <br /> JOB ADDRESS/LOCATION dAed A CENSUS TRACT <br /> Owner's Name (� NR L /� Phone <br /> T <br /> Address A)• .L � -C i1 O, City <br /> Contractors Name ( QBE jfi{%s License 11 Phone <br /> v V <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _Z/� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> \/1 Domestic/private Drilled Dia. of Well Casing <br /> �"- - <br /> Domestic/public Driven Gauge of Casing 7� adt _ <br /> Irrigation Gravel Pack Depth of Grout Seal �P <br /> Other i Rotary Type of Grout _2 TND / <br /> i Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFQTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information true to the be of my knowledge and belief. <br /> SIGNED - TITLE ' <br /> (DRAW T PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE S'O 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II •GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATES--Z • ]�/ INSPECTION BY _ 4' DATE S' 7 <br /> 1A11 rano ♦ nnrolm TAteD= TT~ TTDTnI Mn !DMMTXlr Amn RTAIAT TAIQVVPT/nN1 <br />