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,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _f—or01zFICZ USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _qj <br /> TJIS PERMIT EXPIRES .l YEAR FROM DATE ISSUED Date Issued 7 <br /> Com fete In Tri Iicate) D! -- / oo <br /> 2rCi-2 jt1" r/ �e€c_ ,� t P P � <br /> Application is hereby :Wade to the San Joaquin Local Health District for a permit to construct <br /> s and/or install the work herein described. , This application is made in compliance with Sant Joaquin <br />' County Ordinance No. 1862 and the Rules and Regulatio _ o f the Sap Joaquin Local health istrict. <br /> A, KJOB ADDRESS/LOCATION�B� � ' �''�' /�� NSUS TRACT _- <br /> 'Owner's Named Phone ' <br /> AddressQo • City <br /> i o <br /> Contractr's Name <br /> ' icense ���Phone <br /> TYPE EOOFIWORK (CYieck): NEW WEL '/ µ DEEPEN '/� RECONDITION DESTRUCTION <br /> PUMP INSTALLATION I I P[3MP REPAIR / / PUMP REPLACEMENT I�T <br /> t <br /> Other../ / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf ..'F ' PIT,PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE � TYPE OF LL _ _ ' CONSTRUCTION SPECIFI A IONS T <br /> tt Industrial Cable Tool Dia.>of Well Excavation <br /> 4' Domestic/private. Drilled Dia. of Well Casing 1 C <br /> k <br /> D mestic/public , Driven .,.. -Gaugef .•of Casing <br /> rigation s— Gravel Pack ,` 17epth of Grout Seal <br /> Other Rotary Type,ofj Grout <br /> Other Other Information`,_ <br /> s <br /> PUMP INSTALLATION: _Contractor <br /> T' e. of Pump' <br /> PUMP REPLACEMENT_ # � / Done1� ,^ 4 '7 <br /> V��tatWork <br /> _ s <br /> F PUMP "tEPAIR: °. ,�_ / / _State Work 'Done <br /> ,DFI,TRUCTION OF-WELT.e Well Diamet _ Approximate Depth <br /> I Describe Material 'anT,Procedure <br /> j I hereby agree -to comply with all laws and regulations of the San Joaquin Local Health,,District <br /> and the StateE of California�pertaini:ng to or. regulating we1Z�'constr-action. Witi�in�FI T EN DAYS <br /> after-completion' of my work on a new well, -Iiwill furnish the San Joaquin Local'Health ,District a <br /> WELL DRILLERS REPORT of the well notify them before putting the well in use. The above <br /> infarmatian true to the 'bes my knowledge and belief. <br /> SIGNED <br /> V/1 7L �• TITLE <br /> t (DRAW PLOV PLAN ON REVERSE SIDE) r <br /> k <br /> F04 PEPARTMENT USE ONLY <br /> PHASE I � DATE -�2 �•" <br /> APPLICATION ACCEPTED BY - -- <br /> ADDITIONAL COMMENTS: ' 4.4 <br /> . JPIL�SE II G OUT INSPECTION PHASE III/FINAL INSPECTION._ <br /> INSPECTION BY t k DATE INSPECTION BY DATE 7-Z >--72 <br /> CALL FOR A GROUT INSPECTION- PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731X <br />