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� s y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..OPFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,3: s9 j4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/p_Z _73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit tocconstruct <br /> and/or install the work herein described. * This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Hedlth District. <br /> JOB ADDRESS/LOCATION G 14 7 N l Lb E" f CENSUS TRACT , <br /> Owner's Name o Phone 93/- S9 67 <br /> Address g+ 6 47 Al All 4112_E=_ 7H_ G� _ City CA 1.1,c <br /> Contractor's Name e— License #26 r,I j Phone frLw <br /> TYPE OF WORK (Check) : NEW WELL '/_/ DEEPEN -/_7 RECONDITION /_/ DESTRUCTION /_ ! <br /> PUMP INSTALLATION / PUMP REPAIR /_/ PUMP REPLACEMENT <br /> Other / / E <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing . ."_ . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation E Gravel Pack Depth of Grout Seal <br /> Other A—,Gravel <br /> Type of Grout - - -- - <br /> .l !Other Other Information <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump - - - H.P. �_ 3 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP UPAIR: / / State Work hone <br /> . w <br /> ,DFgTRUCTION 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 ox-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 knowledge and belief. ' � <br /> SIGNED <br /> (DRAW P. OT PL ON REVERSE SIRE) <br /> FOR DEPARTMENT USE ONLY � <br /> PHASE I � <br /> /Z, z <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION B DATE ff �.� <br /> - CALL 4OR-A'GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> L E H 1426 . /73 im Y -� <br />