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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 Permit No.,3 s-4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ��0�.�• zc��~f30�0 <br /> f Application is hereby made to the San Joaquin Local Health District for a permit to co struct <br /> and/or install the work herein described. This Application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name hone <br /> - hone ,'—r �,q_ <br /> Address 1912Z f L1 )Q0. city <br /> Contractor's Name . G ... 5 -75 f� License # Phone <br /> S A <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN_/7 RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION'/ / PUMP REPAIR /—/ PUMP REPLACEMENT /? <br /> Other / / � <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LAVES PTT PRIVY <br /> SEWAGE DISPOS FIELD dnL-e CESS OL/SEEPAGE PIT THER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 f, T <br /> IL Domestic/private Drilled Dia, of Well Casing - 6 - ,:57/5? 1' _ 3 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation V Gravel Pack Depth of Grout Seal <br /> ! Other f,/ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION.- Contractor <br /> TYP e• o f Pump _. . _ c .U 'h� hs r — H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,AESTRUCTION 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 tting the well in use. The above <br /> i information is true to the best of my know . dg and e r <br /> 01 <br /> kSIGNED ,4f TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT DISE ONLY <br /> PHASE I r -w <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P ROUT INSPECTION P I NAL INSPECTION <br /> k INSPECTION BY DATE INSPECTB DATE Z-2-L �Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />