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evalit- SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOF.,OFFICE USE; /1""'1601 E. Hazelton Ave. , Stockton, Calif. <br /> - - <br /> Telephone: (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--33D 11�r-) <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1662 and the Rulexb. and Regulations of the San Joaquin Local Ilezl,th District. <br /> JOE ADDRESS/LOCATION <br /> q491;? V:E- CENSUS TRACT <br /> Owner's Name / � 7 Phone*" ' <br /> Address <br /> City S5 <br /> Contractor1-`Tib` U t�`�I <br /> 3 e )--B 'hone �6 570/'s NameLicense t <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP =EMENTF /_7 <br /> Other ?z <br /> SEPTIC TL14K SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Other Other Information ' <br /> PUMR INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtEPAIR: j-7 State Work Done <br /> t <br /> DF`-TRUCTION 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 and belief. <br /> SIGNED TITLE Gt.ra e J -- <br /> (DRAW PLOT PLAN ON REVERSE SIRE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATEADDITIONAL COMMENTS:PHASE II GROUT Ie_�ON PHASE III INAL INSPECTIO <br /> INSPECTION BY DATE _ INSPECTION By�l DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDS--FINAL INSPECTION. <br /> w <br /> - __ 5/731M <br />