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1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ,ff 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V, Telephone: (209) 466-6781 <br /> fi APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3�Il7 <br /> ys�ia/7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 7� <br /> (Complete In Triplicate) 0 53--fdc— 3 <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 /> C7 C7 w¢CL-Ag:�t- AO <br /> f <br /> 'j- <br /> J'4 ADDRESS/LOCATION � � CEIJ�SUS TRACT a <br /> -0. - <br /> owner's Name Phone <br /> Address <br /> City ' <br /> �� , _ <br /> a -Cont--ractor's Name Ar ,LiC/.t'J( License <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /7 DESTRUCTION /-7 <br /> [ PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> r Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4,- <br /> 6. CONSTRUCTION SPECIFICATIONS fNO <br /> INTENDED USE - TYPE OF WELL _© <br /> Industrial Cable Tool Dia. of Well Excavation ray <br /> Domestic/private ' +T Drilled ," Dia. of Well Casing Y,Z <br /> Domestic/public _ Driven Gauge of Casing <br /> Y` Irrigation Gravel Pack Depth of Grout Seal --�� <br /> C Other Rotary Type of Grout <br /> 4 <br /> Other Other Information <br /> r <br /> PUMP INSTALLATION: Contractor <br /> -- Type of: Pump H.P. "F <br /> I PUMP REPLACEMENT: /�/ State Work`-Done - - <br /> PUMP REPAIR: / / Stage: WorkiDone - <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> [ D'escribe Material and Procedure <br /> I hereby agree to comply with all Paws 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'inew 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 /> informationi rue to :therst pif my knowledge and belief. <br /> R <br /> r <br /> TITLE i r, <br /> SIGNED <br /> RAW PLOT PLAN ON REVERSE 'SIDE FOR DEPARTMENT USE ONLY <br /> PHASE I g <br /> DATE <br /> APPLICATION ACCEPTED BY <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. 7/72 IM <br /> E H 1426 <br />