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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: �1601 E. Hazelton Ave. Stockton, Calif, <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 1"Nermlt No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 023 — 0'f0-3V <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 /> ..�,n� <br /> JOB ADDRESS/LOCATIONn1�� o�J'f/ _KT /yZ Qy�/ /y ,C/ G /nl ENSUS TRACT <br /> Owner's Name Phone <br /> Address Q . yc-A!P€NI City <br /> Contractor's Name ` r _ License #1'/,V-1 Phone j' � <br /> moi- sc <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION W 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 ti <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout .� <br /> Other Other Information <br />._PUMP INSTALLATION., Contractor f'�t)t a'L s � <br /> Type of Pump ACL - H.P. <br /> PUMP REPLACEMENT: State Work Done Fj5/J R 1,U <br />__PUMP REPAIR: / / State Work Done s <br /> .ti <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 and belief. <br /> r' <br /> SIGNED , TITLEiy�/VC7oc <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION ACCEPTED BY6�.Jv DATE <br />: ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION V PHASE III/ INAL INSPECTIO /�,/ <br />'t INSPECTION BY DATE INSPECTION BY DATE 0 1 r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M i, . <br />