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SAN JOAQUIN LOCAL HEALTH DI <br /> POR . STRICT <br /> OFFICE USE: <br /> _ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.173- ,2//4) <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date 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 / �,Z, / r �r l CENSUS TRACT <br /> Owner's Name - <br /> ``11 Phone�IJJ <br /> Address l .� G� i� <br /> C i tY�/1J(� �!► ..` <br /> Contractor's Name <br /> License #2 82,9"hone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION _ <br /> _/_7 DESTRUCTION /_7 � <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> = IndustrialCable Tool Dia, of Well Excavation —� <br /> -----Domestic/private Drilled Dia. of Well Casing <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 - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP REPAIR: / / State Work Done j <br /> . f <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure ---� <br /> f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> r <br /> and the State of California pertaining to or regulating well construction. 'Within FIFTEEN DAYS <br /> after completion of r&y 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 TITLE ,Y <br /> (ARAW PLOT PLAN ON REVERSE SIDE) " <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYzg� <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I _ OUT NSPECT_ION PHASEFIN INSPECTION <br /> INSPECTION BY / •DATE -/d�- _3 INSPECTION BY DATE <br /> CALL FOR fJ NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />