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V ev SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUit No.,,�?-/7Z !a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Compldte In Triplicate) 1�. ©as,_ <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 madeincompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3 5"f4 ;E - i �,J- <br /> JOB ADDRESS/LOCATION /I y ,� q CENSUS TRACT <br /> Owner's Name eC � Phone 24 Y—6 l 7 Q <br /> Address City <br /> Contractor's Name _ License # 3 73Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION / / DESTRUCTION /W7 <br /> PUMP INSTALLATION / PUI ' REPAIRrPUMP REPLACEMENT -7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY F, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation f� <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing , <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> -- <br /> Other Other Infarmatian <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPREPAIR- � State Work Done <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 San Joaquin Local Health District <br /> hand the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 myknowledgeand belief. <br /> SIGNED656e� D"t-LJ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE), -- --- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROW INP TIO PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � � DATE—7—:-, 7,- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. (? <br /> E H 1426 7/72 1M <br />