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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 2 // <br /> 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/6 "p <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 r4z) - _ Phone <br /> �t <br /> Address c�C Co. .�'�r P� City so� e lc <br /> ,Contractor's Name License # /H 7,AS Phone llj�a 7 � <br /> �• <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /% RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR Y/ PUMP REPLACEMENT /7 dA ' <br /> Other <br /> Gr <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 P► <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 <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor, e,ll 4 <br /> Type of Pump `"T�► H.P. <br /> G,o <br /> PUMP REPLACEMENT: / / State Work .Done <br /> PUMP REPAIR: /x/ State Work Done /�,a,�,/„ c _ l,►1 � , pC d- �d �.._._ <br />.pESTRUCTION OF WELL: Well Diameter, <br /> 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 abed notify them before putting the well in use. `The above <br />' nfortnation'is true to rhe~ est''of 'my knowledge 'and belief. <br /> SIGNED ! � TITLE �f. <br /> AW-PLOT PLOT PLAN '0 VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION..BY DATE INSPECTION BY DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.4' <br /> E H 1426r. 7/72 1M r <br />