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N TnAQU1N LOCAL HEALTH DISTRICT , <br /> �_F.'OR OFF1 USE: .1601 E, Hazelton Ave. , Stockton, Calif. <br /> 3 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE� iSSUED <br /> {{ F Bate Issued •. <br /> zPo,J .;e,� , (Complete In Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct <br /> Joaquin- <br /> and/or install the work herein described, This application is made in compliance with San Joaquin- <br /> ' <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaqui Local Health Distract. <br /> -JOB ADDRESS/LOCATION f. s oo 10 sor,�,,,rr ! <br /> r R•{ O ff d.(r u4EN S LIS TRACT <br /> Owner's Name 6 a � �� <br /> Phone <br /> Address / 116 <br /> 4p ,� <br /> . City � <br /> Contractor's Name <br /> 111,771 <br /> License # Phone W�_-74;pz <br /> TYPE OF WORK (Check): NEW WELL / J DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PULP INSTALLATION / / PUMP REPAIR 4W// " PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: ' SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL � <br /> CONS <br /> Industrial TRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.' of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1 Other <br /> OtherGravel Pack Depth of Grout Sea-l ' r <br /> • Rotary Type of Grout <br /> Other Other Information ; a <br /> PUMP INSTALLATION: Contractoror <br /> i w <br /> Type of; Pump <br /> H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: Stlte Work Done eyr d <br /> ESTRUCTION OF WELL: Well Diameter { <br /> •Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />?RASE I <br /> FOR DEPARTMENT USE ONLY <br /> r ,_.. <br /> 1PPLICATION ACCEPTED BY + <br /> IDDITIONAL COMMENTS: DATE ` <br /> PHASE II GROUT INSPECTION r PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE- - INSPECTION BY <br /> BATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 <br /> 7/72 1M E <br />