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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. ;- Stockton-, Calif. <br /> Telephone: (209) 4E6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT' Permit No,� <br /> THIS PERMIT EXPIRES 11YEAR 17ROM DATE 'ISSUED Date Issued <br /> cls 5' wT .7y <br /> I -_ '€T; {Com 3Z <br /> Application is hereby'made` San• Joaquin Lo alrHealthtDistrict for a ermit to <br /> P 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 /> JOB ADDRESS/LOCATION <br /> /C/ CEN d .0 <br /> SUS TRACT <br /> Owner's Name / <br /> �f � � Q A,' Phone ' <br /> Addressr4 ( AA zii / <br /> - mac( , 0 c City <br /> Contractor's Name License #. <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL/DEEPENRE <br /> - �/-- CONDITION /_7 DESTRUCTION, /-7- <br /> PUMP INSTALLATION /; ,-,— UMP„REPAIR ' .,,/ _ PUMP . PLAC_MENT <br /> �.� <br /> ther <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 <br /> Domestic/private : Drilled Dia. of Well Casing J <br /> ,Domestic/public l Driven Gauge of Casing <br /> l- —Irri ation <br /> g 1 Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> i Other Other Information , <br /> 1. <br /> PUMP INSTALLATION: Contractor .� <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 4 <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> ' •• � Approximate Depth " <br /> --.----- =-- �-- -....,,,.,:..�Descri-be:Mat-eral .and�Proceduxe .���.,•.�,;�;-�:.:.:= - <br /> I hereby agree to comply withiall 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 to the best of my knowledge and belief. <br /> SIGNED TITLE t.P/[�t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FO DEP 'NT USE ONLY <br /> APPLICATION ACCEPTED DATE - 7/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I If INAL INSPECTION <br /> INSPECTION BY DATE — - ; INSPECTION BY DATE <br /> I` <br /> CALL FOR A GROUT INSPECTION PRIOR T0. GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4172 1M <br />