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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 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 . , <br /> - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructs, <br /> and/or install the work herein described. This application- is made in compliance with Sari Joaquifi• <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 7 r CENSUS TRACT <br /> Owner's Name ChtePhone 3 ZZ <br /> Address 1160 <br /> City <br /> Contractor's Name _` dDr License #,.? Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR /L/% MP REPLACEMENT /_7,, -.. . [� f <br /> Other / / �/l <br /> T <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled ,ter 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 INSTALLATxON o" " Contiacto�.,.._....,._a..,"-,.i.-�•.�.-,.,.".`: '�... ._,._- - - y,_...,.., � - -- - -. " f <br /> Type of Pump 4 H.P. <br /> PUMP REPLACEMENT. / / State Work Done <br /> ri P ,zS <br />"PUMP . /State Worn'-.Done;REPAIR: <br /> - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> S <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. I <br /> SIGNED ' ` TITLE ,- <br /> zz <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 ' <br /> ADDITIONAL COMMENTS: G, <br /> PHASE II GROUT INSPECTION PHAS !I]I/FIIJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _�ssr <br /> CALL "F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />