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SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 -7— a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73/p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 A.2 3 �, �,�, G/�� CENSUS TRACT <br /> Owner's Name .<<,.c Phone If 16[,(6a[j <br /> Address City <br /> Contractor's Name <br /> License #,T72301 Phone X77-12S-�f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION //K PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL � <br /> CONSTRUCTION SPECIFICATIONS Vj <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing M <br /> Domestic/public Driven Gauge of Casing rte ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> _ Other Other Information <br /> PUMP INSTALLATION: Contractor Z65`7,6/ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 15 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe Material and Procedure <br /> i <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 iii use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> (DRA PLAT PL ON REVERSE SIDE! <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' <br /> PHAU II44OUT INSPECTION PHSIII/F AL INSPECTION <br /> INSPECTION B -DATEINSPECTION BY DATE t� — <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br /> i <br />