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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 -E. Hazelton Ave.. , Stockton, Calif. <br /> VVV Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:%.' ?_- (9-C) tJ i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y.-6-1 <br /> (Complete In Triplicate) A-�/J: 1,,O - 25v-3( <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 .Joaquinl <br />,,County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> 2-9:8 t' w: cu 47 470 $CVD_ <br /> .108 ADDRESS/LOCATION /LC (2Iietzw . G IDU .4 In t W U4 CENSUS TRACT <br /> Owner's Name �_� f/7 0 I e� --C-- "gym S Phone4�2 d�z Q e <br /> Address <br /> E _ ' <br /> City <br /> U <br /> Contractor's Name W � VV `� ` <br /> R K. License # Phone <br /> I e <br />,.-TYPE-OF--WORK-(Check): NEW-WELL //" 'DEEPEN RECON6ITION /_� DESTRUCTION /� N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / �!G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �r <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 /> 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP REPAIR- / / State Work Done <br /> .11 TRUCTION OF WELL: We11' 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 nota them before putting the well in use. The above <br /> information to a best of my n edge and belief. <br />( SIGNED f TITLE <br /> z(AAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> . P I <br /> . APPLICATION ACCEPTED BY DATE <br /> ( ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION P!jqoIr AL INSPECT <br /> INSPECTION BY DATE INSPECT( DATE <br /> t <br /> CALL I'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 7/72 -lM <br />