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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date <br /> Issued �--�-7,Z <br /> fid ^ ,�'9 'l C Lie VA94;2�.'3 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> r 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 o£ the Sa Jo <br /> gain Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT <br /> I CJ 2� <br /> Owner's Name <br /> t <br /> " Phone <br /> Address <br /> '��-- City <br /> Contractor's Name License # Phon <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /'7 - <br /> PUMP <br /> INS TION <br /> Other PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other i/ / y`t- — I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> k SEWAGE DISPO FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial _� Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Dia <br /> of Well Casing <br /> Domestic/public � <br /> I Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other ^- I Rotary Type of Grout , <br /> I Other . <br /> Other Information <br /> I. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . <br /> _ H.P. 4 <br /> PUMP REPLACEMENT: / State Wo Done . <br /> PUMP REPAIR. /._/ ;State Work:Done ! <br />,DESTRUCTION OF WELL; Well Diameter <br /> - �L�"32.L�-�L Arrraximate Depth <br /> Describe Materia nd Procedure <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 Distriet 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 <br /> TITLE , <br /> (DRAW_RLOT PLAN ON REVERSE SIS ' <br /> O' <br /> PHASE I DEPART ' T USE ONLY <br /> {` <br /> APPLICATION ACCEPTED tufa <br /> ADDITIONAL COMMENTS: DATE <br /> INSPECTION <br /> II GROUT INSPECTION P III F NAL INSPECTION <br /> INSPECTION BY DAVE INSPECTION BY,----,) <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br /> �_ <br />