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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.2o1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) -66< <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 +�tthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��rmv ! y r <br /> ` T n eqSUS .TRACT <br /> Owner's Name Lawrence Aze Phone <br /> �t <br /> Address 1122 G a City <br /> Contractor's Name Han Joaquin Pump Comn , Inc. License # 273800 Phone 69w8477. <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal W <br /> Other Rotary Type of Grout f� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor San joanuin 2= C <br /> Type of Pump 3 HP GouldH.P. <br /> _.3. <br /> PUMP REPLACEMENT: / / State Work Done P9 <br /> PUMP REPAIR: <br /> / / State Work Done <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 be of my knowledge a belief. <br /> . i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) N. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ;7-� <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 3M <br />