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WSANJOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , '-Stockton, Calif. <br /> *" Telephoner (209).::4°66=-6781. <br /> PLICATION FOR WELL CONSTRUCTION:'OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES ."'Date =Issued "� 7 <br /> � .k 4. c•STz�: t-211 --(Complete In Tr•ipll atb) <br /> Applicatz,oW;is:,.hereby-a.made•.r.to 'the,-:San,,J.oaquin" Local Health District} fbr.'a�-permi't: to'-consrriict x <br /> and/or install the work herein described. Thi s,applicati-ow isamade`in'!compliance with,:San-Joaquin <br /> County-;Ord-dinarNgAi, 862 and�the,'Rules and=Regulations iof the, San-'j Joaquin Local'°Health-District: <br /> ` I '� o "£tr ff;: ',3 i '�'- s r•^a �?`r:.' :`r,r r •.r'.- ;t - <br /> JOB ADDRESS/ TIN ! .�. S S' RA CTI,0.Q:f- .o�z4r2.�o <br /> V.°^f<)qo-:f4 S'.10 i.,n I ci�.t „i'f 42 a e`•`><.: .a <br /> Owner'-8 iT.w:e•a s ' x.17 F..rf,> .. h i€.} c:r k .4 :C .tc.Phone-, c41 <br /> Address ,/ city <br /> Contractor's NameLicense # 'hone <br /> A y <br /> TYPE OF WORK (Check): ' NEW WELL / / DEEPEN /% RECONDITION /_7 DESTRUCTION /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 SPECIFICATIONSy^ <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> } Domestic/private Trilled Dia. of Well Casing t <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 _._ s <br /> • L <br /> Type .f rumorr <br /> PUMP REPLACEMENT: / / State Work Done. \? <br /> ' f <br /> PUNK' REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL:. Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree to comply with. all laws and regulations of the San Joaquin Local Health District <br /> andEthe 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 welland notify them before putting the well in use. The above <br /> informationrue to the bi! of my knowledge and belief.. <br /> Ae <br /> SIGNED f. I TITLE' <br /> - W LO PLAN ON REVERSE SIDE) <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS-: <br /> PHASE II GRO T - P INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE - - v <br /> CALL FOR A GROUT INS C I P OR vGROUTING, AND FINAL I <br /> E H 1426 4/72 1M <br />