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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ! Telephone: (209) 466-6781 <br /> I QAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,?.?- <br /> -7 <br /> S- <br /> ss` <br /> THIS PERMIT EXPIRES 1 YEAR FRN DATE ISSUED Date Issued /p_Tg <br /> ii (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This-application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations-of the San Joaquin Local Health District, <br /> !' �; • <br /> JOB ADDRESS/IACATION i T L� eE.�il . hr•r�,_. CENSt15 TRACT <br /> Owner's Name Phone <br /> it <br /> AddressCity <br /> Contractor's Name License #,16 a 3 73Phone(o r S <br /> TYPE OF WORK {Check}:�! NEW WELLDEEPEN /' / RECONDITION � DESTRUCTION /_7 <br /> PUMP INSTALLATION k5? PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � 40 A/ V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ii Cable Tool Dia. of Well Excavation l " <br /> Domestic/private il Drilled - Dia, of Well Casing <br /> Domestic public <br /> Driven Gauge of Casing <br /> Irrigation r Gravel-Pact Depth yof 'Grout Seal <br /> Other '" Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATTONa �:J,Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �/ I/ State Work Done <br /> PUMP REPAIR: 1i/7/,,. State Work Done <br /> ,RESTRUCTION OF WELL: iWell 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true tol,the best of my knowledge and belief. <br /> i SIGNED �,���- TITLE <br /> a (DRAW PLOT PLAN ON REVERSE SIDE) ._ <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED BY DATE ��7�7� <br /> ADDITIONAL COMMENTS: 1- <br /> PHASE II GROUT INSPECTION PHASE IUIFINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION -BY ti DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72, 1M <br />