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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:, 1641 E. Hazelton Ave. , Stockton, Calif. �j <br /> ` Telephone: (209) 4666781 �%d 6 76 73 -1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ... <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `r 3-73 <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 Rulesf and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION_�Q Q �Cc/• CENSUS TRACT <br /> Owner's Name <br /> ' Phone <br /> Address City <br /> Contractor's Name• Llpnamr - License #/. one <br /> 1.A „-r <br /> TYPE OF'WORK (Check) : NEW_WELL /X DEEPEN /_%' RECONDITION /_� DESTRUCTION /7 i <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES PIT PRIVY fl l,J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,j f <br /> Industrial µ'Cable Tool Dia. of Well Excavation <br /> Domestic/private ,r Drilled ,Dia.:- of ,Well Casing4L. g <br /> Domestic/publicr ;~' Driven 'Gauge of'Casing` / T - - - ...r <br /> ,. <br /> Irrigation Gravel Pack - Depth of Grout Seal' . ;' D <br /> Ofher Rotary Type of Grout f �! <br /> Other Other Information ,, <br /> PUMP INSTALLATION: Contractor <br /> M Type of !Pump �, t H.P. 1 <br /> PUMP REPLACEMENT:�4 4r s . _. <br /> F ;/f'/. S tate Work Done_ <br /> PUMP REPAIR: /% State Work Done of <br /> .RESTRUCT'ION OF WELL: Well Diameter TM 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 a£ Californiapertaining 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 potify ,them-=before-putting the well in use. The above <br /> information is true o the best of my,knowledge and belief. f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON, REVERSE' SIDE <br /> FOR DEPARTMENT.USE ONLY <br /> PHASE I <br /> :APPLICATION ACCEPTED BYE. _DATELAz <br /> )iD]DiT�10—NA--L'"-C-O—M"M-F-,-N'TS C3 7 _ <br /> . " �PHAS --II..-GR <br /> OiJT-INSPECTION <br /> INSPECTION BY �° DATE TNSPECTiON,BY DATE 1 3 <br /> CALL FOR , GROUT INSPECTION PRIOR TO `GROUTING AND-'i1N"AL INSPE ION, <br /> E H.-.1426 7/72 1M C.1 <br />