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_-_ SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> Cy PLICATION FOR WELL CONStRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? (, -7 z <br /> (Complete In Triplicate) <br /> Application. is• he by.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 Health District. <br /> JOB ADDRESS/LOCATION /�� ({tr---- --„ CENSUS TRACT <br /> Owners s Namer Phone 5�j <br /> Address City <br /> jj <br /> .Contractor's Name IL22W7 d License # Phone <br /> TYPE OF WORK (Check): NEW WELL I DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION ./—/ —PUMP, REPAIR / / PUMP REPLACEMENT /? <br /> Other /-7 <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 6+ � <br /> Industrial, Cable Tool Dia. of Well Excavation <br /> �X Domestic/private y- Drilled Dia, of Well Casing %A <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal o - <br /> Other ---V Rotary Type of Grout <br /> Other Other Information 1- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> :PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> `A -reby 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 I <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 %ieil in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED igam- - _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .._. .._._., •—•-••-•-•--- -• FOR DEPARTMENT USE ONLY -..•..•_._--•..-•----•---.----..__ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEY__7 -- <br /> ADDITIONAL COMMENTS: ! <br /> PHA E Il GROUT INSPECTION ,PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTI� BY DATE 7 Z. <br /> CALL FOR A ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> E H 1426 4/72 ' 1M <br />