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7SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F(:) ..0£'PICE USE: -160,1 E. Hazelton Ave. , Stockton, Calif. <br /> . j Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -tea ?3 <br /> (Complete In Triplicate) <br /> Application is hereby made" tio 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 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> r� <br /> JOB ADDRESS/LOCATION CENSUS TRACT . <br /> Owner's Name --mlec he. <br /> e --[i/jC2s: r Phone <br /> Address v�� '- �. �i� /7�/LP City <br /> Contractor's Naze %i�Se Af License # Phone <br /> s <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN,-/-,//, RECONDITION� �{�— DESTRUCTION <br /> PUMP ,INSTALLATION I / :PUMP REPAIR IL- PUMP REPLACEMENT I� <br /> Other'./ / -- — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY- <br />` t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cry`; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dofiest.ic/ ivate Drilled Dia. of Well Casing <br /> Domestic/public `�; Driven ;Gauge of Casing <br /> Irrigations Gravel Pack Depot of Grout Seal <br /> Other ! Rotary - Type of Grout; <br /> ii Other Other Information . _ _ <br /> PUMP INSTALLATION: Cont:t'actor =A -7- <br /> Type!sof Pump H.P. + <br /> PUMP REPLACEMENT.: I / ` State Work Done t <br />'� PUMP 'tEPAIR: /r State Work Done <br /> 4 <br /> DFCTRUCTION OF WELL: Well Diameter �. � Approximate Depth <br /> Describe Material and Procedure ' <br /> I hereby agree to comply wifhall laws and regulations of the San Joaquin Local Health District n <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 �es.t of my knowledge and belief. <br /> a <br /> SIGNED TITLE <br />' t (DRAW PLOT PLAN ON REVERSE SIDE <br />' FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED .BY DATE//1�7 <br /> ADDITIONAL COMMENTS: Z1.Z L.2 <br /> �. <br /> PHASE If_A_Q%L;?1_N§VtCTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 12-6-7.Ly <br /> - CALL FOR A-GROUT I PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 f/71 I'M <br />