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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 41 <br /> FOiOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. '. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date.Issued o? � 73 <br /> (Complete In Triplicate) <br /> Application isThereby made to 'the San Joaquin Local Health District for a permit to construct <br /> is <br /> Codnor install the . rk 1862eandntheesRulesdandThis Regulationsto£nthe SaneJoaquincompliance <br /> HealthSan <br /> District.. <br /> County Ordinance No. 1$ <br /> JOB ADDRESS/LOCATION L.J ! Y CENSUS TRACT <br /> -Y dfJ itx� 7- Phone <br /> Owner's Name ` <br /> City <br /> Address C.. . ." <br /> Contractor's Name " +rte-+-x-~' License # f 4rj 1 Phone <br /> TYPE'OF`WORKY'(Check) : NEW WELLR--IV DEEPEN /—,/ RECONDITION / 7 DESTRUCTION nTT ., <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEWAGE DISLINES <br /> DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONS <br /> Industrial Cable Tool , Dia. of Well Excavation <br /> Domestic/private Drilled Dia. ,of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout!1G� <br /> Other Rotary Type of Grout �' <br /> Other Other Information <br /> 0 <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> F V <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPYREPATR74 /�/ S�`ate Work'pone <br /> ... <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 an 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 well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> 5TGNEI? <br /> (` TITLE �1. �- <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I rf DATE 0- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FSPECTION <br /> PHASE II GROUT INSPECTION DATE •� _.S"-'7� <br /> INSPECTION BY !1�'' DATE � - L./ J INSPECTION BY <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. 7n72 1M (y_' <br /> E H 1426 `�% <br />