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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. 111 <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F- 0- 7 v ' <br /> (Complete In Triplicate) <br /> Application is .hereb 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 Z-.3. °] L EA IZA1 2 0 CENSUS TRACT <br /> Owner's Name ,,// -� /^ y ^§ Ise! /)1 "/YjJ( Phone ' <br /> Address a 47 3� 7,5':2 _ City .5 l 0C Ir— 0 JV <br /> Contractor's Name W/64zL •� 0 u 1p CQ License # Phone Gz-fig <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN/-7 RECONDITION /7 DESTRUCTION /- I <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS rJ <br /> Industrial Cable Tool Dia. of Well Excavation /0 <br /> _ Domestic/private Drilled Dia. of Well Casing _ L <br /> Domestic/public Driven Gauge of Casing j Z <br /> Irrigation Gravel Pack Depth of Grout Seal '?> _ <br /> Other - - Rotary Type of Grout G <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor C-44/?-tl C,L tet- /Ig (J IP C-6, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - ' / / State Work Done <br /> PUMP REPAIR: / / State Work• Done �. <br /> I <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 /> 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 isftrue to the best of my knowledge and belief. <br /> SIGNED _ TITLE C19/V 71rl !Q <br /> - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ! _ ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT PHASE II/FINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BX DATE17 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP CTIO <br /> E H 1426 4/72 1M <br />