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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOR OFFICE.USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. ,,k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73`1714lo <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) T��F/— /7D ---0 z_ E <br /> Application is hereby made tothe :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'Ryof 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION dip `b �}C e7�J CENSUS TRACT <br /> Owner's Nam;90 <br /> PhaneAddress �� �� ' � � <br /> City <br /> Contractor's Name _ 16/;F-Z-77 %yU 1�-l�S---A,A7 License #1 16x313 Phone lod 9��5 <br /> i <br /> TYPE OF WORK (Check): NEW WELL jT/' =DEEPEN /_/ RECONDITION DESTRUCTION ,/_? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER " �] <br /> INTENDED. USE TYPE OF WELL I . ,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 4 <br /> Irrigation ;l Gravel Pack. Depth of Grout Seal i ^ <br /> Other ii.. . aRotary Type 'of Grout <br /> I Other 1 Other Information <br /> PUMP INSTALLATION: o. Contractor 4 <br /> r <br /> 7 Type of Pump V H.P. <br /> REPLACEMENT: <br /> /7 ' State Work Done- <br /> PUMP � �,,, _„ r t per;► _W <br /> PUMP REPAIR: ' / / State Work Done <br /> i b <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> J' bescribe '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 r .�- a> �` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEY <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE % �� <br /> ADDITIONAL COMMENTS: <br /> zz <br /> PHASE II GROUT INSPECTION P II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B ,1,,,/ DATE Z <br /> CALL FOR A GROUT INSPECTION.;PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M q <br /> R <br />