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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.7.3-3 F/ ld <br /> THIS¢PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3->� <br /> -�'" 'f�"` :�` -�►-Cc �2c�£r - (Complete In Triplicate) 2L��!-�7�3•-�7 - <br /> Applicationis3hereby,made �td- thek-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 andRules and Regulatio the San Joaquin Local Health District. . <br /> JOB ADDRESS/LOCATIONCENSUS TRACT S' ' <br /> Owner's-Name' f 7.t. Phone' <br /> Address <br /> Contractor's Name License !l S0 Phone A Q_� r -1 ' <br /> TYPE OF WORK (Check) :. NEW WELL / DEEPEN / RECONDITION /� DESTRUCTION /� -- <br /> PUMP INSTALLATION /_--t_—PUMP REPAIR / / PUMP REPLACEMENT /7 �^�� <br /> lv <br />� Other / / Va <br /> DISTANCE TO NEAREST: SEPTIC TANKy (SEWER LIKES IT PRIVY <br /> SEWAGE DISPOSAL FIELD ._6t CESSPOOL/SEEPAGE PIT' THER <br /> INTENDED USE Air TYPE OF WELL. CONSTRUCTION SPECIFICATIONS . <br /> Industrial . Cable Tool Dia. of Well Excavation- . " <br /> Z__-Vo_mesticj-private Drilled Diat-of Well Casing60S <br /> Domestic/public.- Driven Gauge -of Casing <br /> �y" .TYpe of Grou.AJ- z �� <br /> Irrigation Gra 1 Pack Depth of Grout- Seal �Q f� <br /> r Other otar t 0:ther_j.,_. Other Information <br /> PUMP +INSTALLATION: Contractor IL/ v p <br /> Type ,o f Pump L✓/V �!'c_ H.P. <br /> / p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State 'Work Done <br /> ,DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material a d Procedure <br /> I hereby '4ree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating swell construction.— Within- FIFTEEN- DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distriet 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 be f my knowledge and ..bel`ief <br /> SIGNED ' ' TITLE gQ fv Cz <br /> (DRAW PLOT PLAN ON 'REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> —0 <br /> ADDITIONAL COMMENTS: _ <br /> P E 11 GROUT INSPECTION P rZ AL -INSPEC• ON_ <br /> INSPECTION BY G DATE "K ,,INSPE ClAelt DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> Y <br />