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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR64FFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: ' (209) 466-46781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72--fl -7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,,- /b Y <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION el�v �,�'�,�, CENSUS TRACT ' { <br /> Owner's NamePhone '' <br /> Phone " <br /> Address 1 3,3 4 City A l, <br /> Contractor's Name ZLicense # Phone '�ak?Qd_ <br /> Alf <br /> TYPE OF WORK (Check): NEW WELL I% DEEPEN '/-/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / I PUMP REPLACEMENT /- <br /> Other /-7 <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 { i <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / /. State Work Done. 11L �,, ►n. &.Lt;27- <br /> .m <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 FIF'TEEk 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. r <br /> SIGNED Glu, ! 1Z� � l C'. �o,,L, �7/ u .j,.) TITLE <br /> t (DRAW PLOD ON REVERSE SIDE) <br /> F It DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE N. <br /> E H 1426 4/72 1M C. 2)- <br />