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SAN JOAQUIN LOCAL HrALTH DISTRICT <br /> FOR OFFICE USE: j , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> (Y Telephone: (209) 466--6781 <br /> / APPLICATION FOR WELL CONSTRUCTION OR PUMP PEkTermit No. <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) r; <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and.the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION C'61 ) CENSUS TRACT k <br /> Owner's Name , Phone <br /> r City <br /> t Address p <br /> License # � 373 Phone <br /> Contractor's Name i(��,/ �,,W.,a ; ,dxT�,z _ �� <br /> `i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/�/ RECONDITION /� DESTRUCTION /-7 , <br /> E PUNK' INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT /- <br />{ Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PIT OTHER "6 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable 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 - M <br /> Other Other Informatim- <br /> i <br /> v4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: / // State Work Done <br /> PUMP_REPAIR: /Y/ State Work Done cILL> n ' e/ - <br /> -- <br /> ,DESTRUCTION 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 � ,, Y), T. _ �, �- TITLE . :, : -1* a,N 4,gd2- — <br /> (DRAW PLOT PUAN ON REVERSE SIRE) <br /> FOR D ARTMENT E a LY-- <br /> PHASE I7 f �7`B � s J1�' �, SI _ /J�7� <br /> APPLICATION ACCEPTED BY r ,J' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE 7 y' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />