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0 <br /> ! <br /> 94 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; �! 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Ip Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y- G <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued id /�- <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. 18fi2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1io) �9 CENSUS TRACT <br /> Owners Name' I�, Phone <br /> - - ' <br /> I' <br /> I Address -----___--- lf�lic.v� City <br /> Contractor's Name License # Phone <br /> I TYPE OF WORK (Check) : ANEW WELL / j DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST; SEPTICTANK .SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE I'� TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private l� Drilled Dia. of Well Casing <br /> Domestic/public ji, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> II Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. .2--�-r <br /> PUMP REPLACEMENT; "% / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> I� <br /> .DESTRUCTION 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 ofJthe well and notify them before ,putting the well in use. The above <br /> information is ue to 'theest of knowledge and belief. <br /> SIGNE z Me TITLE Al;,ezt2�444 <br /> i <br /> < (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4h <br /> APPLICATION ACCEPTED BYI DATE <br /> , ADDITIONAL COMMENTS: °! <br /> PRASE IY, GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BYDATE �, INSPECTION BY DATE Z Z2 <br /> --- x <br /> CALL FOR A GROUT INSPECTION PRIOR? TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />