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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFVICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,27 <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 — ,�/ herd r e -- CENSUS TRACT <br /> Owner's Name Pell ,9-222 LL--f4 Phone 931- ��9� <br /> Address Ghe -Z) -Ze A City x.YA e,�--4r7._ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN / / RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALI47 N / I PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / _ ./!/irJ � U10- <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 /> Other Rotary Type of Grout 1 <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type Pump T e of Pu <br /> PUMP REPLACEMENT: / / State Work Done A <br /> PUMP REPAIR. / / State Work Done+ ° <br /> Q <br /> ,DESTRUCTION_ OF WELL: Well Diameter Approximate Depth ! d <br /> Describe Material and Procedure <br /> F 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 /�y�JiLlGr/�f <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR PARTMENT USE ONLY <br /> PHASE I ^-�— <br /> APPLICATION ACCEPTED B jXr DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE.2— — <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />