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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> w <br /> Telephone: (209) 466-6781 `� F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Permit No. -lc <br /> r <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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAATyION 0 CENSUS TRACT <br /> Owner's Name d'�`�'`� �� �L--fg e_aL�%_ Phone <br /> 9'a/e 9 ,D C' <br /> Address f L-� 1� City 07c77C�Zf�,4'J <br /> Contractor's Name I' License # #--�.?73 Phone <br /> t <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION }/� ' <br /> PUMP INSTALLATION / / PUMP REPAIR / /: PUMP REPLACEMENT / <br /> Other /_7 - <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY + <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE TYPE OF WELL CONSTRUCTIOE3 SPECIFICATIONS <br /> Industrial � Dia. of Cable Tool Dia, of{ Well_ Excavaiion <br /> Da <br /> p W <br /> uyestic/privateer �* �. _ � Drilled, •,,, • ,�- Well'"�Casing " <br /> Domestic/public Driven Gauge of Casing . .. <br /> + Irrigation Gravel Pack 1Depthtof +Grout Seal <br /> Other "'Rotary RType" of Grout <br /> I Other s Other information 3 <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 49/ State Work Don't - -'�"� <br /> k � - <br /> PUMP. REPAIR._ :_..� /- %_State .Work Done ..- ..� .��-- �, - - -- =• <br /> .2ESTRUCTION 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> k information is true to the best of my knowledge and belief. ' <br /> f <br /> i SIGNED eta . TITLEerg/ <br /> (DRA PLOT 'PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 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 7/72 1M <br /> k <br />