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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6731 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z <br /> - TRIS "PERMIT EXPIRES l YEAR IROivi°'DATI 'ISSUED Date Issued �- /D •7i <br /> (Complete In Triplicate) <br /> Applicati n is hereby made to the San Joaquin Local Health Di.str`ic.t 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 /> JOS ADDRESS/LOCATION z7j_49 CENSUS TRACT ' - <br /> Owner's Name r eve ® Phone ' /J <br /> Address ,�i91.,s. �J-9J _ City <br /> Contractor's Name License Phone' • ` <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN '/ RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK rs° SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL ' # CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool=,—. .v Dia. of- Well Excavation <br /> Domestic/private Drilled Dia.'of Well Casing <br /> Domestic/public. r. - N 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 V- C Uw,�/e =zP& <br /> Type of Pump .2 &A � H.P. 2_ <br /> PUMP REPLACEMENT: ( / State Work Done <br /> PUMP REPAIR: / / 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 /> a d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> z2 ter completion of my'work on a new well, I will furnish the San Joaquin Local Health District a <br /> ALL DRILLERS-REPORT of the well and notify them before putting the well in use. The above <br /> informati i true. t0 th best f my knowledge and belief. <br /> k SIGNED '� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> . APPLICATION ACCEPTED BY - DATE 7 Z <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPEC ION r <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 4/72 1M <br />