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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z:�,3`3 / CENSUS TRACT <br /> Owner's Name &a 72772 le E& Phone <br /> Address 4 30 42 192. ���.i'•h 6 (2a Wi t-- City <br /> Contractor's Name License #,p2o, Phone `' C <br /> TYPE OF WORK (Check) : NEW WELL /,C/ DEEPEN/—/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/—/ PUMP REPLACEMENT /-7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK p 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 ,,' ' L11Domestic/private Drilled Dia, of Well Casing _ r <br /> -! Domestic/public Driven Gauge of Casing f `4 <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout 2�-• <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ,77�na AV1 e"n _ <br /> Type of Pump �.�.� 71+E,W ,,_ H.P. �.. <br /> PUMP REPLACEMENT: / / State Work Done <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. The above <br /> information is true to the be t o my knowledge and belief. - <br /> SIGNED TITLE{DRAW PLOT PLAN ON REVERSE SIDE) <br /> V 4 _ OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT /�f /{� DATE f` Z-- 7�__ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL aNSP ION. <br /> E H 1426 4/72 ,IM <br />