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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .&-d_L2 <br /> HIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 0q-7- <br /> by �FCa.73 <br /> Application is hereade t' 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 /> �' O O +.J Vii✓ i'�E.Al,r tiC.d r p <br /> JOS ADDRESS/LOCATION V X1tp CENSUS TRACT <br /> Owner's Name c neOln 'klam_r YA gym_C-A .rr4-- Phone <br /> Address - ------- City � <br /> Cl tractor's Name � ,e,� � n? i,1 License # hone , .-� <br /> -- -- - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_ /�/ RECONDITION /H DESTRUCTION /_7 <br /> PUMPINSTZLATIOV PUMP REPAIR / / PUMP REPLACEMENT /7 �* <br /> Other F/ i <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES PIT <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE -TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I_ Cable Tool Dia. of Well Excavation <br /> , Domestic/private Drilled Dia.. of Well Casing <br /> C� Domestic/public Driven `=Gauge of Casing <br /> Irrigation Gravel Pack .`r Depth of Grout Seal <br /> ' Other ! Rotary Type of Groutj <br /> ! Other Other Information d <br /> PUMP INSTALLATION: r Contractor <br /> Type sof Pump H.P. t .0 <br /> PUMP REPLACEMENT: '' / / State Work Done <br /> PUMP REPAIR: / / State Work Done IP44,11®Z F <br /> V <br /> J)ESTRUCTION 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. The above <br /> information is true to the best of my knowledge an belief. <br /> SIGNED k) e � TLE <br /> 11 jj (DR4 PIAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I. <br /> APPLICATION ACCEPTED 'BY DATE <br /> ADDITIONAL COMMENTS:' <br /> PHASE II P ION PHASEII14FINSPECTION <br /> INSPECTION BY DATE INSPECTION BY SATE _2-0-77Z_ <br /> } CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E <br /> H-1426. 7/72 1M <br />