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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />,j FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t-- - d I Z_,�,,Q�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 220-77 <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. 186 and the R les and egu a ion �the Sap Joaquin ca Health District. <br /> �� f �W,re <br /> JOB ADDRESS/LOCATION ./3a7 - US TRACT <br /> Owner's Name Phone <br /> Address c69'- City 4- <br /> Contractor's <br /> Contractor's Name i License # V Phone,36 --3: 3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /_� DESTRUCTION /'7 <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 /> i INTENDED USE TYPE OF WELL t <br /> CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled-., Dia, of Well Casing v <br /> Domestic/public Driven , Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump w H.P. d <br /> PUMP REPLACEMENT: / / State Work Done <br />" PUMP REPAIR: _ <br /> _/ / State Work Done <br /> ESTRUCTION 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 /> SIGNEDA!4AIco -VTITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />; APPLICATION ACCEPTED BY DATE z <br /> ADDITIONAL COMMENTS: A Ii <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY� DATE _— INSPECTION BY DATE - <br /> 22 <br /> CALL FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />