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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> C Telephone: (209) 466-6781 <br /> f o-o <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:� <br /> THIS PERMIT EXPIRES l 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 /> i and/or install the work herein described. This application is made in compliance with San Joaquin <br /> cd the Rules and Regulations of the San Joaquin Local Health District.,,.,,, <br /> County Ordinance No. 1862 an . <br /> lA Gi/^ CENSUS TRACT <br /> - <br /> JOB ADDRESS/LOCATION -26/ ' 1/ /V /JR <br /> e f <br /> Phonef <br /> Owner's Name a-Y+ = �' <br /> r a City <br /> Address 41 <br /> Contractor's'Name cC�va License # / 4s-n Phone <br /> sz- <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Geo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED,USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial SC Cable Tool Dia. of Well Excavation /911 <br /> X - 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 f Type of Groutc � <br /> Other Other' Information <br /> PUMP INSTALLATION: Contractor /arc� ,�c�tia-�/ � �* �- A �� / -- <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 s <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 SLG, b'- TITLE <br /> DRAW P PLAN ON REVERSE SIRE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEL---- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE .3 INSPECTION BY � DATE /6--7-$ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. yup <br /> E H 1426 7/72 1M <br />