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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .•OrFTCL" USE: /1601 E. Hazelton Ave. , Stockton, Calif. ff <br /> Telephone: (209) 466--6781 <br /> : :APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. Zi <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE "ISSUED Date Issued 1,2-a T 74 <br /> (Complete In Triplicate) { <br /> Application is hereby lade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the world herein described. - This application is made in compliance with San Jbaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION ,OLj CENSUS TRACT <br /> Phone <br /> Owner's Name d �� � <br /> Address <br /> S"3 I� C' Y U G P/2 Jf1Q City <br /> Contractor's Name Q License #.o 40-79VPhone :Jr o. <br /> TYPE OF WORK (Check) : : :NEW WELL & DEEPEN '/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR I I PUMP REPLACEMENT /-7 <br /> k <br /> Other .l I <br /> DISTANCE TO NEAREST: SEPTIC TkNK 42 d !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 /> x D6mestic/private' Drilled Dia. of Well Casing `` I <br /> Domestic/public � , � Driven Gauge of Casing /loa *,.5-C Al <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other _ Rotary Type of Grout ,S 4f -_- — ,cC <br /> Other Other Information ' .� <br /> PUMP INSTALLATION: � Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: A / / State Work Done <br /> DESTRUCTION OF WELL: ' IWel1 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 FIt!'TEEN 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 ffirue to the best of my knowledge and belief. <br /> SIGNED Gi JI TITLE <br /> 7� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .ty DATE,0- <br /> ADDITIONAL COAUP ENTS: I <br /> PHASE IIjGROUT INS ECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY Ip DATE INSPECTION BY '7 DATE /;7-7 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS TION. <br /> E H 1426. M; 5/731M cc <br />