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SAN JOAQUIN LOCAL HEALTH DTSTP.ICT <br /> FOR OFFICE USE: 1.601. E. Hazelton.Ave..; Stockton, Calif. <br /> Telephoner (209) 466. 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.X? <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED ; Date Issued // 8=-'�' <br /> (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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 711 CENSUS TRACT 's'/,7 <br /> Owner's Name J C F� Phone Ej� <br /> t Address .! G f'/ / /,� City 'QG <br /> f Contractor's Name � r / 1 _ l- �---- -�---_ License IV `Phone <br /> TYPE OF ,WORK (Check) : NEW WELL / EEPEN / / RECONDITION /_/ DESTRUCTION J� 1. <br /> PUMP INSTALLATION / J PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE :DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i' <br /> industrial Cable Tool Tia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 2- <br /> Irrigation Gravel Pack Depth of Grout Seal �U <br /> Other Rotary Type of Grout fsczc '! _T t x <br /> Other Other Information " <br /> PUMP' INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR: . / / State Work Done <br />�. ,DESTRUCTION 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 /> F. 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 fiL(ll7/9{- <br /> E (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 64 <br /> PHASE II GROUT 'INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Z A -p - INSPECTION BY 110 DATE /2-- 73- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />