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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : ' (209) 466--6781 <br /> PLICATION,.FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z•/D Z <br /> THIS- PERMIV EXPIRES 1 YEAR FROM 'DATE.ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is ereby �made to .the San 3oaq6in 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 t _ S' /1-70 IV A D CENSUS TRACT D f3--6T-0-32— <br /> Owner's NamelaitiA c r -z y Phone 5f <br /> Address. City oa/_ <br /> Contractor's Name ettr. _40_1t� License # c� yPhone 7�i4^ro S` <br /> TYPE OF WORK (Check): NEW WELL Z DEEPEN /_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /X PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> r Other /_7 <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 �y <br /> Domestic/private . Drilled Dia. of Well Casing g <br /> Domestic/public Driven Gauge of Casing •� _,....... ___._. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout .., <br /> Other, . Other Information I '^ <br /> PUMP INSTALLATION: Contractor <br /> < - <br /> Type of Pump H.P. - - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 <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 Gft-pir � jD, y� (DRAW P � .. 0 R /,TITLE <br /> ! REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " <br /> t''APPLICATION--ACCEPTEDTBY"' ` DATE <br /> ADDITIONAL COMMENTS: .. ' .1 +"1 . V'►` k <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE O �- <br /> CALL FOR A UT INSPECTION PRIOR. TO. GROUTING AND FINAL INSPE ON. ' <br /> E H 1426 7/72 IM C <br />