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SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif.Telephone: (209) 46�678_1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z3,3 8'7kJ <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued3 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONI eCENSUS TRACT <br /> Owner f s Name Phone Cj/- ,J3yl� <br /> Address Lk <br /> Lto City <br /> S84L .S <br /> Contractor's NameLA44 paauadLicense #J,2.67.?1/ Phone 7j_)4) <br /> TYPE OF WORK (Check): NEW WELL X DEEPEN / / RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_/ PUMP REPLACEMENT /_ <br /> Other L1 — <br /> DISTANCE TO NEAREST: SEPTIC TANK_?4 6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C1 - _ <br /> INTENDED USE TYPE OF wFXL CONSTRUCT ON CIFICATIONS <br /> Industrial �X _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 14 A2 Al, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done Ilk <br /> — T <br /> „pESTRUCTION OF WELL: Well Diameter ate pth <br /> Describe Material and Procedhre <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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d/3/7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INAL INSPECTAON <br /> INSPECTION BY DATE INSPECTION BY 9TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />