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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .:or,or, USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> � . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-S"/3 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/a.. 7-5` <br /> ,• (Complete In Triplicate) <br /> Application is hereby made, '4o the San Joaquin Local Health District for a permit to construct <br /> application is made in compliance with San Jpaquin <br /> and/or install the work herein described. ' This <br /> d the Rules and Regulations of the San Joaquin Local health District. <br /> County Ordinance No. 1$62 an <br /> �, v / <br /> 1 JOB ADDRESS/LOCATION / NSUS TRACT <br /> Phone <br /> Owner's Name ALU <br /> 1 t } City . . <br /> Address <br /> It7Contractor's Name <br /> License �� hone <br /> TYPE OF WORK (Check) : NEW WELLf/ DEEPEN J / RECONDITION I / DESTRUCTION l"T <br /> PUMP INSTALLATION / / pump REPAIR / / PUMP REPLACEMENT /? <br /> Other ./ / <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r�1 <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation .- <br /> Domestic/private Drilled. Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 65, <br /> Other )( Rotary Type of Grout 1� <br /> —7� Other Other Information [� <br /> w PUMP INSTALLATION: Contractor \ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PLiMP:, .PAIR:., ...,... � . ,�J��+ State Work-Done <br /> DF'gTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> #i <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 <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 /> i TITLE - <br /> �t SIGNED DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE.ONLY <br /> { PHASE I <br /> APPLICATION ACCEPTED .BY DATE «. -/-7 s <br /> ' ADDITIONAL COMMENTS: i PHASE IIT/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY LTE10 TSCTiON BY <br /> - <br /> CALL-FOR A-GROUT•INSPECTION-PRIOR - GRO TIN AND..FINAL INSPECTION. - 5/731M <br /> �' •G` T7 I A 7 C. - <br />