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r e <br /> rf � SAN JOAQUIN LOCM -HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU,'IP PERMIT Permit No. ,7 314 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issueds -_�_� <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,r186Z., and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s p ¢ : CENSUS TRACT �Zv Lf—6550-2 _j <br /> Owner's Name60 '{r7,//� . <br /> Phone7. <br /> Address City <br /> Contractor's Name License #f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION / PUMP REPAIR /—/ PUMP REPLACEMENT /? W <br /> Other /% a <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> fA <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3 <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 /> Type of Pump IF I/ H.P. <br /> PUMP'REPLACEMENT: J% State Work Done ': ,�`�1i1?ttc� � _-- <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 /> informatli�oon�is true to the best of my knowledge and belief. <br /> SIGNED G�/�^✓`«4 <br /> =A�Z4 --,,_g <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �"_'•__ "— r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �', DATE '3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTION <br />, INSPECTION BY DATE INSPECTION BY &ZJ2; - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />