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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> f Telephoner (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -72�- 23 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4Z <br /> (Complete In Triplicate) �4 <br /> Application is hereby- made to the 'SaA Joaquin Local Health District for a permit to construct <br /> and/or install the worst 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 Cl4.4 J ,i_v1d 4. 919 ZWENSUS TRACT _ <br /> Owner's Name l e-a q <br /> t Phone <br /> Address 4 / City - e., <br /> Contractor's Name `-' License # /gam 9hL-�Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /^/ rrRECONDITION /_7 DESTRUCTION 1-7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> de Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type of Grout .' <br /> I <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor -4 <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: J' / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />-pESTRUCTION OF WELLt 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 /> TELL 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 /> SIGNS <br /> (DRA P T E ON RE R5E SIDE <br /> DE ARTMENT USE ONLY <br /> PHASE I Q/ <br /> APPLICATION ACCEPTED BY DATE 0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 41- 2-) <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />