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SAN JOA:QUIN LOCAL HEALTH DISTRICT ' <br /> FOR/OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif-. ' <br /> ¢� Telephone: (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.172..: a u1 33 <br /> 4 6 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T,j <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 DX trict. <br /> a_ rAj: 623--ae-o c? ' <br /> f,7 <br /> JOB. ADDRESS/LOCATION '� l' "� ? ` lr CENSUS TRACT <br /> Owner's Name .z �.�2k� Ci �f� Phone A <br /> Address D� City <br /> Contractor's Name �f� �3c ,.�-� License ��� [?' Phone��/ ® � <br /> E�OFTWORK-(Che'cit)':�-�VEW*-WELL;-/�EEPENz/�I '��CONDTT'ION��AR�RI�C-Ti0I3•=-/? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� U1 <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 /> f Industrial ' P Cable Tool Dia. of Well Excavation 01 IN <br /> 4 k-lbomestic/private ° Drilled Dia, of Well Casing <br /> I Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Cher <br /> k _ _ Other Inf rmati n <br /> I <br /> PUMP INSTALLATION: Contractor <br /> 2 Type of Pump H.P: d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- j�/ State Work Done ': <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <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 Californiapertaining 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 /> SIGNED 2 TITLE s /� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO EPARTMENT 'USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B C.. S DATE <br /> ADDITIONAL COMMENTS <br /> PHASE Ii GROUT I PECTION NAL INSPECTION <br /> C. E"' <br /> CTION BY TIS CT N Y DATECALL-FOR A GRflU 1'E N:PRI O GROUTING AND FINAL INSPECTION. <br /> H 1426 6e, !r� 7/72 iM <br />