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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 :. Hazelton Ave. , Stockton, Calms. <br /> Telephone: (209) 466-6781 <br /> APPLI 1`i FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.•� 3 w <br /> THIS ,RMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to re San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is maSoa an Joaquin <br /> County Ordinance No. 1862 and tl�t" ules and Regulations of the SaFRACTa District. <br /> JOB ADDRESS/LOCATION , wa+fG�•�sr ,�' <br /> Owner's Name (i- Phone s,/O <br /> Address �l•J`d T "'' t_ � � City ��T ► <br /> Contractor's Name ®G2Coe License #Z007,9f Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATIONPUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,+'` <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Other Rotary Type of Grout Er — <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump �i .<:+P -�„�,� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 EX work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP of the well and notify them before putting the well in use. The above <br /> informati a to�the-best-of ,my knowledge and belief. <br /> SIGNED ��° >* _ <br /> e t �'° TITLE <br /> ,7-(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY 4f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE &I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /o 7 INSPECTION BY DATE J� - S-Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> C� <br />