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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> ,.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17 <br /> 7-7- <br /> THIS PERMIT EXPIRES 1. REAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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. 1.8 2 and the Ru es d Re ulations of Van. Joaquin Local Health District. <br /> /sYEW <br /> JOB ADDRESS/LOCATIO �.C9c. . S � / TRACT <br /> owner's Name ` /V Phone <br /> Address 300 City <br /> License #1f 7 <br /> Contrac or's Name S 0 � 2 Phone 3 $ 33 i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 !' <br /> PUMP INSTAL TION PLW REPAIR / / PUMP REPLACEMENT /-7 <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 Z2 -J, . �. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing • + <br /> Irrigation Gravel Pack Depth of Grout Seal 4a <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor O ZC <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / j State Work Done <br /> - A <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFcTRUCTION 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 /> i SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br />�. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> E APPLICATION ACCEPTED .B DATE 1.3—73 <br /> ADDITIONAL COI,'Ei NTS: <br /> PHA E II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE j/Z3 INSPECTION BY ,��„ i DATE /p �,.Lg_�-?'/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. I! /ry <br />