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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton.,, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. JZ -3 6 <br /> { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 -.7 <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. Regulati-ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tTs�L ..W�, ..; CENSUS TRACT f Owner's Name. <br /> Name. asL t /7 b 5 <br /> Phone ' 2 if g 5-- <br /> Address <br /> City S TkN G L <br /> Contractor's Name A s L .� <br /> L - License # 72,3,p�Phone z.1Z7/,grp <br /> r TYPE OF WORK (Check) : NEW WELLN DEEPE _ <br /> .� _/7 RECONDITION /_� DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR I I PUMP REPLACEMENT / �. <br /> Other� / / <br /> N <br /> DISTANCE TO NEAREST: SEPTICrTANK _ SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT a OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS o <br /> Industrial Cable Tool Dia. of Well Excavation <br /> — Domestic/private Drilled Dia, of Well Casing `mow <br /> Domestic/public i Driven Gauge of Casing <br /> Otthher �. k <br /> egation Gravel Pack Depth of Grout Seal - roo , <br /> Rotary Type of Grout <br /> . 1 Other Other Information <br /> PUMP INSTALLATION: Contra Ictor <br /> Type of Pump <br /> i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: � � <br /> / / State Work Done <br /> . EESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> r v <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 knowledge and belief. <br /> SIGNED <br /> -� TITLE <br /> ( PLOT LAN ON REVERSE SIDE) <br /> _PHASE I E FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE _'Lv�b- <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � - DATE �L�,7 INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION:..PR..I0R TO GROUTING AND FINAL INSPECTION. { <br /> E H 1426 <br /> 4/72 �1M <br /> 1 <br />