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F <br /> SAN JOAQUIN LOCAL-.'HEALTH DISTRICT <br /> FOE.:OFFICE USE: 1.601 E. Hazelton Ave. ; Stockton, Calif. <br /> ^� Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> THIS PERMIT WIRES .1 YEAR 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 Jaaquii <br /> County Ordinance~.No..*1862 and .the Rules and Regulations .of -the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION ... uJ{d CENSUS TRACT , <br /> Owner°s Name e;la 4W4.100 ! ' Phone <br /> Address• � .�..�..,.�..=�.� City . . _ <br /> Contractor-'s- Name 17V / . ,,.` License # Phone NX <br /> TYPE OF WORK (Cheek) : NEW.,WELL /_7 DEEPEN/% RECONDITION j / DESTRUCTION /_7 <br /> PUMP'' INSTLATION' / / PUMP REPAIR /�(/ PUMP REPLACEMENT {� <br /> AL <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 <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 /> - w <br /> PUMP INSTALLATION:' Contractor 1 <br /> Type of Pump c*-r H.P. \ <br /> PUMP REPLACEMENT: i / State Work Done <br /> i <br /> i PUMP 'tEPAIR: <br /> LK State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and .Procedure <br /> s <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 b`efore'putting the well in use. The above <br /> . information is true ,to th.e best y k ow ge nd belief. <br /> P SIGNED TITLE <br /> r <br /> MPILOT PLAN ON EVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY . <br /> � PHASE I / - <br /> APPLICATIONACCEPTED BY, a�� DATE <br /> `I -)- -A <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> --CALL-FORw-A GROUT INSPECTION,PRIOR TO GROUTING•AND-FINAL-,--INSPECTI99-/L..( 14 , <br /> E H 1426 <br />