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F <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOR OFFIC SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:;--3_2�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,5-_2-,73 <br /> „(Complete In Triplicate) ��� _ 1-7D —06 <br /> Application is hereby made to the Sa;O,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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI5,00-- N ° CENSUS TRACT <br /> Owner's Name <br /> �' �-clr�c�u. Phone '%6S= <br /> Address ZjLf D — �' #t to . .°...._ ,_.._ <br /> _. City J � <br /> Contractor's Name ,t License #TLLfL,3r Phone Z <br /> TYPE OF WORK (Check) . NEW WELL DEEP RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATI / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> � r <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 ] rrj <br /> Industrial Cable Tool Dia. of Well Excavation _ - <br /> , Domestic/private Drilled Dia, of Well Casing _. <br /> Domestic/public Driven Gauge of Casing <br /> _ X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Te .of Grout . _ <br /> Other Other Information -------------- <br /> ' <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. t <br /> PUMP REPLACEMENT: / / State Work Done <br /> s <br /> a <br /> PUMP REPAIR: / J 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 /> 121 SIGNED TITLE I l a�Xr <br /> (D PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C6-� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ROUT INSPECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECd r <br /> E H 1426 1 7/72 1M <br />