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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' Date Issued ..<-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 /> ;,� <br /> JOB ADDRESS/LOCATION , 217 ENSUS TRACT <br /> Phone -0 <br /> Owner's Name <br /> ,rN City <br /> Address 7 <br /> I� 1373 Phone3 <br /> Contractor's Name License 4�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION <br /> r PUMP INSTALLATION // PUMP REPAIR f /'TPUMP REPLACEMENT /� <br /> 4 .. Other / / <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ► OTHER <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Dome,stit/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 /> Pv 9r <br /> PUMP INSTALLATIONt Contractor <br /> s Type of Pump <br /> PUMP REPLACEMENT: .� / / State Work Done <br /> �- -- State Work"Aone <br /> PUMP REPAIR: T -- <br /> 9 � <br /> te Depth <br /> 2ESTRUCTION OF WELL'" Aroxi: Well Diameter pp imap -----�---- <br /> f - Describe Material and Procedure <br /> I 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 /> TITLE <br /> SIGNED <br /> a (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R D MENT USE ONLY <br /> f <br /> PRASE I C <br /> APPLICATION ACCEPTED BY pv Y z DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2E-tom�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 ~ <br />