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�,. SAN JOAQUIN LOCAL II'EALTH DISTRICT <br /> FOR OFFICE USE: ': 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ct'u 5 °l <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7 0- 7 Z <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 /> f <br /> JOB ADDRESS/LOCATION 13977 C&F/@ a K e L..ED I CENSUS TRACT <br /> Owner's Name 0 G!a " Phone 3(,ga o y z --- <br /> Address 7 CA-En L- 1-/V City 4-0 D f <br /> Contractor's Name 7 &AL NAME'R License #.�J230Phoney77-/SS-y <br /> TYPE OF WORK (Check) : NEW WELL, -DEEPEN / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK ljonoo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> w <br /> INTENDED USE TYPE OF WELL CONSTRUCT N SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well\Excav ion <br /> Domestic/private Drilled Dia. of Well i <br /> mestic/public Driven Gauge of Casing \ i ! <br /> Irrigation Gravel Pack Depth of Grout Se <br /> Other Rotary Type of Grout 7� <br /> Other Other Information ' <br /> PUMA INSTALLATION: Contractor <br /> Type of Pump 2. 1 H.P. /yo <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: / / StateWorkDone <br /> .DESTRUCTION OF WELL: Well Diameter 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 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 ander belief. <br /> SIGNED .,o ��' _-,yl __fir _ TITLE <br /> (DRAW FILOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY C, �I _--_ - DATE b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2Q " - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />