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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. Z-5 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM• DATE 'ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �l^2. [a Phone <br /> Address a t 7-71 City C74 40640- <br /> Contractor's Name 1Cf 400 '�'d License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN '/% RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other.. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <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 Grout Seal �S <br /> T Other Rotary Type of Grout <br /> Other Other Information (" <br /> PUMP INSTALLATION: Contractor' } <br /> Type of Pump H.P. .,.� <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / / State Work Done rzc <br /> MM <br /> ESTRUCTION 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 oil 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 k 1e d belief. <br /> SIGNED J LE /r . <br /> D W PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> r DATE6 It �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 44M DATE INSPECTION BY DATE / <br /> I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. <br /> E H 1426 4/72 IM <br />