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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. 7 z- 73 y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 y1v <br /> ry.z <br /> +� (Complete In Triplicate) �' <br /> /O��- ZS�o- <br /> Applicatlon 'is hkereby mad6 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 nd Regulations of thq, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j,Q d*` @ et. a ' U CENSUS TRACT , <br /> Owner's Name . ra��a- - - "��- Phone 473 /C ge& <br /> Address �px_ r' - G 4) 1- Cx A4 kaAft a1L City (GL <br /> r <br /> Contractor's Name License #/ 1 7)�C`Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_-7 'DESTRUCTION /_7 i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 �! <br /> Other / / <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY P' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <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 +•f: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .`& `, I►°i + H.P. <br /> PUMP REPLACEMENT: / / State* Work Done <br /> PUMP REPAIR: / / State Work Done ^ Q J;4 <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 best of my kn a and belief. <br /> SIGNED ITLE <br /> 'XIDRAPLOT PLAN EVERSE SIDE ._ _. <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> "INSPECTION BY DATE INSPECTION BY DATE I <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSP ON. <br /> E H 1426 7172 1M G� <br />