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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FO OFFICE USE: 160 . E. Hazelton Ave. , Stockton, Calif. o <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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 o / G, c cce4 CENSUS TRACT <br /> k <br /> Owner's Name -�Dr� - ,.-c.Q _Trc�c� i.� .� Phone <br /> Address _ ao�'/ - �✓�� ✓- City �' <br /> Contractor's Name `9:�5 License # Phone <br /> L 3 <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /a(7 <br /> Other <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. 'Di'a. of Well .Casing. <br /> 'Domestic/public .-` briven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _Z:2) <br /> Type of- Pump — -- !� d H.P. Zsr <br />'i PUMP REPLACEMENT: / State Work Done , a/1I_da01-7-_Z;Ll �// �� i <br /> PUMP REPAIR: / / State Work Done <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 on a new well, I will furnish the San Joaquin Local Health District a <br /> IWELL 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 /> (f ( RAW PLOT PLAN ON44EVERSE SIDE <br /> i Y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASEjvII FI AL INSPECTION: <br /> INSPECTION .BY DATE INSPECTION BY DATE S� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />