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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,2 -77P <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 Rales and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a13 ' JI14" b.'re, iE _-- CENSUS TRACT <br /> ` 1 <br /> Owner's Name �►"r AXZZ �1�' Phone - — <br /> Address r City [_ <br /> Contractor's Name stip License #,i25_2LI:�-Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTALLATION REPAIR / 1 PUMP <br /> CEMENT 17 <br /> Other Jam/ �/��Itr�r�e 41 r' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS {'J ; <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> _ �C.. Domestic/private Drilled Dia. of Well Casing I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 7 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> F <br /> PUMP INSTALLATION: Contractor Sd��✓ ��� <br /> Type of Pump H.P. /p <br /> PUMP REPLACEMENT: / / State Work Done 't <br /> PUMP REPAIR: State Work Done 'ret fjQ� j+G -�� r'r r 110 <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 is true to the best of my knowl ge belief. <br /> f <br /> SIGNED / � ITLE <br /> ,41 (D W T PLAN ON R RSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY266 dq 9- DATE 3 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEt=jIIjFINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />