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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 0 FILE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 456--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. k) <br /> 73- <br /> THIS PERMIT EXPIRES 1 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 Healthp District. <br /> 17 <br /> JOB ADDRESS/LOCATION a Off' , CENSUS TRACT J <br /> Owner`s Name Phone?-27./5� <br /> Address.Qoab �o. .c-r=fs-.cam_ rfo ae d-�Gt Com ! _ City <br /> Contractor's Name a �f <br /> '713 ° License #1,L0 <br /> "-Phone Z'P7-3 <br /> f <br /> TYPE OF WORK- (Check) : -NEW--WELL DEEPEN / / RECONDITION -/7-DESTRUCTION /_7 <br /> PUMP INSTALLATION V/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / ! <br /> DISTANCE TO NEAREST: SEPTIC TANK $ D- SEWER LINES S�O 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 C <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 <br /> s - <br /> Type of Pump rzAZ7 -- H.P. p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 /> informatio true to best of my knowledge and belief. <br /> _ <br /> SIGNED TITLE - - <br /> (DRAW PLOT PLAN ON REVERSE.SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f D3 DATE/ A_/23 <br /> 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Q - 7 -:;P 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 4/729 1M <br /> H 1426 <br />