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( ` <br /> SAN JOAQUI°i7 LOCAL HEALTH DISTRICT <br /> FOF O;rpICE USE: 1601 E. Hazelton ,Ave. , Stockton, Calif. <br /> Telephone: {.209} 466-6781 /per <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17,�t, <br /> el <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 3^u_7 <br /> y (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install theworlc herein described. This application is made in compliance w th .San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health D�s�rict. <br /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name ��t _ _ 3 `•`" �n�� V �'� Phone - 7° <br /> Address City <br /> Contractor's Name <br /> License #/Za?;j(,3 Phone-q�43 V •77. <br /> . _ -•ice-_ ;,,. "M r _ <br /> t. TYPE OF WORK (Check) . NEW <br /> WE J_ EEPEN / / RECONDITION / I DESTRUCTION f-7 <br /> PUMP INSTALLATION % / PI;W REPAIR I / PUMP REPLACEMENT I�T <br /> Other / / <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> { DIS SEWAGE DISPOSAL� -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i INTENDED USE # TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cj <br /> Industrial ,--ftKe Tool Dia. of Well Excavation I o <br /> -D6mestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J Q <br /> Irrigation Gravel Pack Depth of Grout. Seal ;5'Z <br /> Other f Rotary Type of Grout V✓1 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor . <br /> H.P. <br /> Type of Pump — <br /> PUMP REPLACEMENT: / / State Work Done <br /> eunr , EPAIR: � - - -�St to Work Don- <br /> DFCTRUCTION 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 <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 /> j SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE}` . <br /> FOR DEPARTMENT USE ONLY <br /> a PHASE I ' <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIx/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . DATE 3 7/----3r <br /> CALLFOR A GROUT INSPECTION.-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> a . 5/73 rt <br /> VV ,A?A ... - <br />