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///1601 <br /> oSAN JOAQUIN I:OCAL HEALTH DISTRICT'FOK,OFF E USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT-„,:, ;:Permit No. 7 3 -31 Q-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued)/i_7/7 3 <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 Ordirifa/nce No 2862 and the' Rules and Regulations 1of the San ;Joaquin Local Health District. <br /> .17 <br /> JW ADDRESS/LOCATIONO / rCENSUS TRACT -� ff <br /> Owner's Name Phone CS' <br /> AddressCity <br /> a � <br /> Contractor's Na me (FW mr-P-1 Ljgnh 4aa!(=ilf.!LV-G-Licjensp--ii.?--ZZ56JPhone <br /> TYPE OF WORK (Check) : NEW WELL k<DEEPEN /_7 RECONDITION`:/_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 i <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Nom; <br /> SEWAGE DISPOM FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE 27,—WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation S <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 /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. - - H.P. <br /> PUMP REPLACEMENT: / /. State Work Done - <br /> ------ <br />- PUMP REPAIR: / / State Work Done ,­: s.> <br /> ,DESTRUCTION OF WELL: Well Diameter '_' _ . '�_„. , ...., .._.,..— Approximate Depth <br /> Describe Material and Procedurb�` <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 we and notify them before putting the well in use. ' The above <br /> information i9113rue to the be of m knowledge and belief. <br /> SIGNED TITLE <br /> (D LOT PLAN ON' REVEkSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BXI / DATE 7,_7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III1 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L',D --- DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 'r <br /> E H 1426 7/72 IM <br />