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C � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Oi.:OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781' v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 'f-7`73 <br /> qj— (Complete In Triplicate) Q(3-2c 0-2--& <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 wade in compliance with Sart Joaquin <br /> County Ordinance leo. 1662 and the Rules and Rpgullations of the San Joaquin Local Health District. <br /> COrovtvoc-we- <br /> i <br /> JOB ADDRESS/LOCATION �(> G v CENSUS TRACT <br /> Owner's Name A z f OS IANC•` Phone div T,c nNa�S ►/f��S� 1 <br /> I <br /> Address AI"/a V 1]7 Q _ - --- City <br /> : License 4�Z6S 76/ Phone 4W 4/ e 1 1 <br /> Contractors Name <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/ I RECONDITION I I DESTRUCTION 1-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR I / PUMP REPLACEMENT I� <br /> Other <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 ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack . e Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ----— Other Other'Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - . <br /> PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter F Approximate Depth <br /> Describe Material and Procedure <br /> 4 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 /> i 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 knowledge and belief. <br /> f <br /> TITLE .e <br /> SIGNED a� a <br /> (D PL DE <br /> LAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> € APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE r'-/ .� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �- <br /> .. .. 5/731M <br />