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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VOR OFFICE USE: , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> J (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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ; CENSUS TRACT <br /> Name ame <br /> � 44 0. � .0 itrg-� Phone <br /> l / <br /> Address at '� „7� !� �� , �� 4 ,�tr City 1_4)<,C' � <br /> Contractor's Name _� License 4i /y� *-. - hone <br /> E F <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /7 RECONDITION /_� DESTRUCTION J-7 } <br /> PUMP, INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /)_e7 <br /> i Other J / <br /> F � <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 v <br /> Domestic/private ! Drilled Dia. of Well Casing -G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �I, Gravel Pack ""Depth -of Groirt--Seal <br /> Other wat4 : Rotary Type of Grout <br /> Other Other Information a <br /> E S <br /> EI <br /> PUMP INSTALLATION: Contractor <br /> Typel of Pump H.P. <br /> PUMP REPLACEMENT; / State Work Done <br /> PUMP REPAIR- / / ' State Work Done <br /> .pESTRUCTION .OF WELL: We113Diameter 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 i,, ,true to the best of my kno 4,,edge and'be of. <br /> SIGNED <br /> i DRA PWT PLAN ON REVER IDE <br /> Wk DEPARTMENT USE ONLY <br /> r PHASE I <br /> ''PLICATION ACCEPTED BY Nvx�A DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> 4 <br /> E H 1426 7/72 1M W <br />