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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 /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7 2 `4'f <br /> I� ( THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' 7-�p_7Z <br /> v (Complete In Triplicate) <br /> Application is hereby made io 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION 3 0 G-r a 5s CENSUS TRACT -Vf7 <br /> Owner i s Name C 4— - Phone '�3I Q F ` 3 <br /> r <br /> Address � �¢ 2 A 17 LF 1 City 1 <br /> Contractor's Name C 14 4-Y �/ c�C Jc" r � License # �77694 Phone ?NQ 3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION "/-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / FUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4 :5' CESSPOOL/SEEPAGE PIT 0 OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation _..._._, W <br /> Domestic/private Drilled Dia. of Well Casing -s <br /> Domestic/public Driven Gauge of Casing C` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information "l <br /> PUMP INSTALLATION: Contractor C ,S' I P <br /> Type of Pump .'9_A RS - ---- - - H.P. <br /> 4 <br /> PUMP REPLACEMENT: / .State Work Done NEW eu 11 5_t/4 'LL 7^/dN <br /> -. -r _ ..aYl� _.,,�. �IY�Yl.rM11 Ir4�11 Y�Y�I�.11� d��� o*-- 4.-��u'cia-F'.- .+Jk•-.�"...+--�x <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well'Diameter Approximate Depth <br /> f 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 Californiaspertaining 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 my knowledge and belief. <br /> SIGNED ✓ TITLE d <br /> (DRAW PLOT PLAN ON REVERSE SIDE FOR DEPARTMENT USE ONLY <br /> PHASE I ` f r <br /> APPLICATION ACCEPTED BY _ °� �tyc Q DATE /2 2— <br /> . ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE, 1141FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - �' <br /> CALL FOR A GROUT INSPECTION_ PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ;y`' . r M <br />