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12-10 7 , <br /> SAN JOAQUIN LOCAL REALTH DISTRICT ' <br /> FOR OFFICE 1601 E. Hazelton Ave., Stockton,., Calif. <br /> Telephone: (209) 466-6781 <br /> A qt APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ®?-1,?. 7�1- f <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 1v1,At 1G'_57-7,✓ dzlflo W CENSUS TRACT <br /> z <br /> Owner's Name A Phone -3 i- 2 -5 <br /> Address t� S., � �S i/ �✓ Ct � �`�f�--ar City <br /> Contractor's Name S i� "i S 2--, <br /> License #.2 mac,3Phone-5' <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN J / RECONDITION /_- /-7DESTRUCTION / <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT J <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOSAL FIELD CE SSP OL/SEEPAGE PIT OTHER o0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G•, <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 1` <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S 7,^A, .s c- -- 5 <br /> Type of Pump H.P. C- C' <br /> PUMP REPLACEMENT: State Work Done •_�o , i <br /> PUMP REPAIR: / / 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. Thea ove <br /> information is true to the best of my knowledge and belief. <br /> SIGNED __���'`��Ce � —�.----� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE III GROVT INSPECTION PHASE IIIJXINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7> <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 2ms ; S_ 4/72 1M <br />