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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AOR OFFICE-.USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> fq/�,g <br /> 40 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7,-) 17 Gtf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9- 22- '72- <br /> (Complete In Triplicate) <br /> Application is ereby 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 /> 7a33b$ <br /> JOB ADDRESS/LOCATIONAl. CENSUS TRACT <br /> Owner's Name 64N aekMl/ ,K' 6A- 1 Phone 6"95-r 34d& <br /> Address C2/41 CX�"72-OAF kd City <br /> Contractor's Name �F,�/,�,/j,(/�5 d�,�r� �L p�/�L/,U n � License # Phone <br /> TYPE OF WORK (Check): NEW WELL A DEEPEN /_-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 �1�1 <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 _ .t,/ If <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ V Gravel Pack Depth of Grout Seal <br /> Other V Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done q��7�TZ .�'' �- t7" <br /> PUMP REPAIR: /% State Work Done <br /> .RESTRUCTION 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 /> k 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ( ;�.�J. DATE Cl 7 <br /> ADDITIONAL COMMENTS: <br /> P GROUT INSPEC ON <br /> PHASE I AL iNSPECTIO <br /> INSPECTION BY-7T DATE i 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />