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JOAQUIN-LOCAL HEALTH DISTRICT + <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3•.7 <br /> (Complete In Triplicate) k <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .end/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 Z0 10 440, elo1 CENSUS TRACT <br /> Owner's Name t ® 4e Phone <br /> Address a "��- !V �� .y- CityC ;?!La <br /> Contractor's Name ` License #�� honef , <br /> TYPE OF WORK (Check) : NEW WELL /=T DEEPENw /7 WRECONDITION I-T DESTRUCTION / 7 F <br /> PUMP INSTALLATION I I PUMP REPAIR ' PUMP REPLACEMENT I_T <br /> P' <br /> Other / / <br /> �D <br /> t 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 <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 a Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. ;X 0 <br /> PUMP REPLACEMENT: / / State Work Done , .. <br /> PUMP REPAIR: LW State Work Done <br /> , ,DESTRUCTION 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 /> information is true to the best of my knowledge and belief. <br /> SIGNSITLE <br /> (DRAW PL T PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BYDATE INSPECTION BY / DATE ,z <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />