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JOAQUIN LOCAL HEALTH DISTRIC,,,, <br /> folrl:o FICE US1:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued LjLg"70 <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 3!a3— 'lY 11- SO N �� y CENSUS TRACT <br /> 1 Owner's Name //p WA 2 D 6A w 7 /� /F/z Phone 478 gG 4(,!` <br /> Address t4/ yoKwTS IV G 1,�/, / S` City 57 c <br /> Contractor's Name2��v[t��2rs-� '.-�w�_ 6>, License U :3.bs-76% Phone 4C ti-9S3\� <br /> ` TYPE OF WORK (Check): NEW W$LL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 ` y <br /> PUMP INSTALLATION / / PLW REPAIR 1_7 PUMP REPLACEMENT <br /> Other <br /> t � <br /> 'DISTANCE .TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I � <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> f _ 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 /> t • <br /> j PU*T INSTALLATION: Contractor �-- �1�7� ���'� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: - / / State Work Done <br /> i <br /> DFRTRUCT10N OF WELL: Well Diameter Approximate Depth <br /> Describe Matirial and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Scate 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 /> A WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the bests of my knowledge and belief. <br /> :! SIGNED /l�iryGt�liiGGr-� /-�" off-" �'f r�• 4r 6.TITLE <br /> + (DRAW P LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY / <br /> i <br /> 3 PHASE I n DATE �� <br /> APPLICATION ACCEPTED BY v� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO T , F.CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT , A 6r• <br /> -CALL•FOR•A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO -� <br /> ►. E H 1426 . -,-- 5/731M _ <br />