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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 -33cu <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- <br /> (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> D _ <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Named Phone W - - 7 <br /> Address <br /> C i t y/L <br /> Contractor's NameLicense #/G 37 3 Phone 3(� i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS p <br /> Industrial >_ Cable Tool Dia. of Well Excavation J� ', <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing `p <br /> Irrigation Gravel Pack Depth of Grout Seal 4 ` <br /> Other Rotary. Type of Grout ��}ry F <br /> Other Other Information t <br /> PUMP INSTALLATION: Contractor 'L.,e_. <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: /, j State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL- Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply -wi -all—laws an gulations-of-the- an oaquiri Local-'Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS s <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 i <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE - — a <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _j!7_30--7j __-- ' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />