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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone:. (.209) 466--6781 <br /> .17APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7EI-lI� <br /> s , <br /> THIS PERMIT :EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (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 herefn described. - This application is made in compliance with Satz Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 740 CENSUS TRACT <br /> Ownerls Names. 1 .Ae � .,,,, ��nun � n _ Phone <br /> Address 6,. 006 ar_,t�c S _o City . . <br /> Contractor's Name. �' - License # / 3 Phone S ' <br /> TYPE OF WORK (Check) : NEW WELL .y DEEPEN '/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /may / PUMP REPAIR /. I PUMP ,REPLACEMENT, J-7 <br /> Other '/ / — <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> •l <br /> K <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia. of Well Excavation 3.2 2 4L <br /> Domestic/private Drilled Dia. of Well Casing ` b" <br /> Domestic/public ': Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 4,— <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4 H.P. A@ o <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtEPAI&: State' Work Done <br /> ,DFRTRUCTION 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 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 TITLE <br /> L <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR 1TMENT USE ONLY <br /> PRASE I ° <br /> ACCEPTEDB) <br /> ATE :�f/- 7 - - <br /> ADDITIONAL COMMENTS: t . <br /> PHA I GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE 3 --7,,/>(-/ INSPECTION BY DATE -�� <br /> ; <br /> CALL F'OR- A..GROUT INSPECTION PRI TO GROUTING AND FINAL INS CTION. iy� <br /> F_ x 1126 5/731M <br />