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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> 1LICATI 6/F R WELL CO STRUCTION OR PUMP PERMIT Permit No. 7 Z L <br /> THIS�PER.MIT 'EXPIRES 1 Y R Ft)M DATE-ISSUED Dare 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION u AcL S �r �4 ct 9 4- a �' CENSUS TRACT " <br /> Owner's Name x� _ . s s• . -- - - -- Phone <br /> Address o . IU _ 1A lb City : <br /> e' <br /> Contractor's Name u License fV Z,C3Phone 7c 5.y'7 <br /> TYPE OF WORK (Check) a NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ I PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> f„ Other / / <br />� I <br /> DISTANCE TO NEAREST: SEPTIC TANK .?0 0 R LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Tool Dia. of Well Excavation O p " <br /> Domestic/private Drilled Dia. of Well Casing . 7-- <br /> Y� Domestic/public Driven Gauge of Casing , /a <br /> rigation � Gravel Pack Depth. of Grout Seal <br /> Other Rotary Type of Grout 4- cfi.,: <br /> Other Other Information <br /> 'UMP INSTALLATION: ' Contractor CL� t'4 Q <br /> -- -IH.P. <br /> Type of Pum~ YP P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / /. State Work Done <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_c. <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 /> SIGNED L�JL�a �_ C_ J �LE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C�.� DATE pZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /,�J_ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />