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nSAN JOA <br /> UIN LOCAL HEALTHi- DISTRI <br /> Q CT <br /> F-OF.:01 FICEv USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-77-,,1, 7sp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IZ-,l 3 <br /> (Complete In Triplicate) / fid-z-0 <br /> Application isherebymade. 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 Health District. <br /> ,JOB ADDRESS JLDCATION <br /> 'Alec �'��y CENSUS TRACT ' <br /> f <br /> Owner's Name Phone <br /> Address o ="��.�=d� r ��.� .ag,0 : S----A1Wjj city , . SO4U"/ <br /> Contractor's Name . License # 93 2�hone f69 - <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ f RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / . <br /> " © r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <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 <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 /> ,.. <br /> Type of Pump 41 H.P. ' 7 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP PU State Work Dome <br /> .DFgTRUCTION 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 al <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 f ktt edge n belief. ; <br /> SIG ED TITLE <br /> W P PLAN ON VERSE, SIDE) k <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY 'z DATE <br /> r <br /> ADDITIONAL CO101ENTS: 4ZIrt <br /> PHASE II GROUT INwSPECTION PHAS TTI/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL -FOR A GROUT INSPECTION PRIOR TO.-GROUTING AND FINAL INSPECT N. <br /> L' iT Z /.nz' ffr/7-1Yv <br />