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,y...- ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT M <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. aj . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S- t7 3 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION 1, d CENSUS TRACT <br /> Owners Name Phone <br /> GG�� _ 8'- 7<71,_ <br /> Address 1�[c�b. S'f l4` f EIzt.EC � _.� City <br /> Contractorts Name License #,'2220 <br /> � Phone <br /> F <br /> _ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /_] <br /> PUMP IkISTALLATION / / PUMP REPAIR-/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1= SEWAGEaDISPOSAL 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 Depth' of- Grou-t Seal <br /> Other Rotary Type of Grout <br /> Other Other Information , <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump a :; ,., H.P. <br /> PUMP REPLACEMENT: fr State Work Done <br />-PUMP-REPAIR-. . . �. F7—S'tate- Work gone- <br />,PES I TRUCTION <br /> one-ESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 rue to the best o my knowledge and belief, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY -- �— <br /> APPLICATION ACCEPTED BY J, DATE {] 3 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br /> . .C� <br />