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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton 'Ave. , Stockton, Calif: <br /> Telephone: (209)' 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z�-g 53 <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued .� .Z 97Tj <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 madein compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local.. Health District. <br /> JOB AuuxESS/LOCATION I04lJ CENSUS TRACT <br /> Owner's Name At aAc f, A-- 'Phone <br /> Address l ,S' 1F.9 ►. City ek-1/19�� - <br /> :a <br /> Contractors Nam" <br /> a b to- License # 49_21,L'Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR ff PUMP REPLACEMENT /_ <br /> Other / a <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 � ,E <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 11 <br /> Irrigation Gravel, Pack Depth of Grout -Seal T <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump , . , H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ESTRUCTION OFWELL: Well Diameter <br /> 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 dge -andbelief. <br /> SIGNEDAh/ LE <br /> (D LOT PLAN ON REVME SIDE <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6? Z_ <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL .F'OR A GROUT INSPECTION PRIOR...TO GROUTING AND FINAL INSPECTI . <br /> E H 142+6 7/72 1M <br />