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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. 7Z--.. <br /> ArA <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issuedj/, <br /> (Complete In Triplicate) <br /> Application is hereb 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 ` 0 'CENSUS 'TRACT <br /> Owner's+ Name y Jf, �, ,::.; ',9laj <br /> ,.� _ Phone <br /> Address .C. ' E=: City <br /> Contractor's Name. License # 14,237-3 Phone <br /> TYPE-OF WORK (Check): NEW. WELL / / rDEEPEN / •/ "RECONDITION° /_� DESTRUCTIO& /7 <br /> PUMP /� <br /> INSTALLATION / J PUMP REPAIR / PUMP REPLACEMENT J�T <br /> Other / / — <br /> e <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �. .; .r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> j Other Rotary Type' af Grout <br /> Other Other Information, <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP REPAIR: ) State Work Done R. RZUj-411u-' l2 d—.42 <br /> 41 ek. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> k 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 /> SIGNEDr TITLE ! <br /> (DW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL PECTIQjq <br /> INSPECTION BY _ _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION b$ <br /> E H 1426 7/72 1M <br />