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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16€31 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��c,U <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Idsued,i�3 <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 / E SUS TRACT <br /> Owne r f s NameLL '�!I•., 'Y 1.r Ph ohe <br /> Address, ! �� /'!/1 �l l � L'12 City E <br /> Contractor's Name License phone� <br /> TYPE OF WORK (Check): NEW WELL /X-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> p <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 � X Drilled Dia, of Well Casing G <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 /> Mi <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. E <br /> PUMP REPLACEMENT: / / State Work Done ; <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> 1 �./ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I - <br /> FOR DEP T 'NT USE ONLY <br /> APPLICATION ACCEPTED Y - / DATE --- (J <br /> ADDITIONAL COMMENTS: <br /> P ROUT INSPECT ON P SE PINAL INSPECTIO <br /> INSPECTION BY DATE ~' , INSPECTI $ DATE <br /> CALLFORF2R A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br />