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"S-AV JOAQUIN "LOCAL HEALTH DISTRICT <br /> �i 0 _ OPFiti� USI:: v 1601 E. hazelton Ave. , Stockton, Calif. <br /> ---. Telephone ; (209) 466-6781 <br /> # APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Z 4,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED':'" Date Issued �V 7,W <br /> (Complete In Triplicate) <br /> ADpiicstion is hereby ;rade to the San Joaquin Local Health District for a permit to const��uct <br /> an;;/or install the wont herein 'described. ' This application is made in compliance with Sar[ Joaquin <br /> E County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION 1�gJ�� �� �/��� /C�►��� �,fy� � CENSUS TRACT <br /> Owner's Name phone L <br /> Address �; r <br /> Cityf �c�.4r <br /> Contractor's Name ® License � a c . ` <br /> ""�'Phone <br /> TYPE OF WORK (Check) : NEW WELL '- DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUiv� INSTALLATION PUMP REPAIR / / PUMP REPLA N� / <br /> Other <br /> DISTAiNCE TO NEAREST: SEPTIC TANK SEWER LINES � X <br /> PIT PRIVY <br /> SE1.4AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTTER <br /> w � <br /> INTENDED USE TYPE OF WELL � <br /> CONSTRUCTION SPECIFICATIflN5 b <br /> Industrial Cable Tool` Dia. of Well Excavation <br /> Domestic/private Drilled � <br /> Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal C <br /> Other - Notary Type of Grout <br /> — Other Other Information <br /> o"n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> P U_"P' REPLACI,HENT: <br /> / / State Work Done <br /> I'U,SP 'ZI PAIR: State Work Done <br /> DESTRUCTION OF,WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 a new well, I will furnish the San, Joaquin Local Health District a <br /> i;N:LL DRILLERS RI�POR of the well and notify. them before putting the well in use. The above <br /> inrormation - to my know . ge nd belief. <br /> SIGNED <br /> TITL <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PJASE I <br /> API'LIC,V ION ACCEPTED BY DAT �7 <br /> ADDITIONAL C0M`1ENTS; _ �' �— <br /> PHASE I GROUT INSPECTION 9 <br /> PHASE III/FINAL NSPECTIO <br /> INSPECTION BY DATE INSPECTION BYO <br /> DATE <br /> s <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> "E 11 14-96 iJI�-' <br />