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SAN JOAQUIN LOCAL HEALTH 61•STRI'CT. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP UCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "] <br /> THIS PERMIT EXPIRES 1 YEAR FROhf DATE -ISSUED Date Issued <br /> zr­ <br /> (Complete In Triplicate) 42b, <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 /> 8Y i <br /> JOB ADDRESS/LOCATION � r. Lp Q ,.� CENSUS TRACT <br /> Owner's Name )U5 Phone <br /> Address <br /> -----sem:. C1tY <br /> Contractor's Name ` .�/ `4 .v w0j License # Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN / / -RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Other / / a — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> a SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r INTENDED USE b TYPE OF WELL ` ,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of"Well Excavation <br /> Domestic/private Drilled Dia. of Weli Casing <br /> a Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal <br /> "Other x ""'~ RoEary - Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION; t Contractor � O <br /> f <br /> Type of Pump H.P. .r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: - . n_ ..,,� _ . 'tlr��j <br /> /�/�,State Work Done00 <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> _. Approximate Depth <br /> Describe Material and Procedure <br /> I herebyre <br /> agree e 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 constructlon. 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 f my knowledge and belief. <br /> I SIGNED TITLE <br /> (DRAW PLOT:PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY V�1 - V G(�' DATE 7L y J 7�2- -- <br /> ADDITIONAL COMMENTS: <br />` PHASE II GROUT INSPECTION PHASR)III/FINAL INSPECTION <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 <br />