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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G FOR OFFICE USE: 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 L <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations o£ the San Joaquin Local Health District. <br /> -i t y �!v : C�7�3 2_0•-'02._ t�Jtf t/,tizc_�I. <br /> JOB ADDRESS/LOCAT1O1rj-0e-& dIj 49S - <:)F7V7,-- -S�NSUS TRACT <br /> Owner's Name � � .� _ 1�: T '� � c&1 -- <br /> *� Phone <br /> Address /`� � <br /> City <br /> Contractor's Name orr'r,� f� License # 1�.I P3 Phone f�&IG <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REP <br /> Other AIR / ./� PUMP REPLACEMENT /_7. � -�� cJ :-L- ---- Q <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 Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> A <br /> Other Rotary Type of Grout y� <br /> --_ _ Other Other Information [� <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR. - I / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Dept d <br /> Describe Ma ial and Procedure 417— <br /> I 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. <br /> SIGNED , TITLE <br /> (DRAW 13LOT PDY ON REVERSE SIDE <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE QIP 23 <br /> ADDITIONAL COMMENTS: --- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI <br /> QN <br /> INSPECTION BY DATE INSPECTIONBY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />