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r /(�� SAN JOAQUIN-LOCA'E HEALTH DISTRICT <br /> FORE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 46.6-6181 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (r " 'i-�t =�+.✓d�= Zt7 (Complete In Triplicate) <br /> ��J6elta"the- Sin �. <br /> Application"3s`hereby Joaquin Local Health District for a 'permit to construct <br /> and/or install the work herein described. This application is maoe, tn compliancewithSan Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the `San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION l* ?,c}• AA,. CENSUS 'TRACT P'70-W' <br /> Owner's Name J, <br /> M `o Phone <br /> Address — -7.d.. ~' <br /> Contractor's Nates License 4f 1-_90'72 Phone k3Vi� -2cr7v <br /> TYPE OF WORK (Check) : NEW WELL I/, / DEEPEN /_7 RECONDITION /_T DESTRUCTION /_7 <br /> PUMPINSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br />' Other / / -4� <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 _ ^ <br /> Domestic/private' Drilled Dia. of Well Casing �./�� A. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> E. A � <br /> PUMP INSTALLATION., Contractor a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> t ,DESTRUCTION OF WELL: Well Diametei " ` - ' -- Approximate Depth <br /> Describe Material and Procedure <br /> I hereb Y 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 /> r <br /> SIGNED TITLE <br /> LL V (DRAW PLOT PLAN ON REVERSE SIDE <br /> Q FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-.PRIOR.TO .GROUTING AND FINAL INSPECTION. - <br /> E H 1426 7/72 IMlfiy <br />