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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. 75-14LIp <br /> THIS PERMIT EXPIRES.�1 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 /> 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 v CENSUS TRACT <br /> Owner t s Name /5 zPh `1~ : <br /> Phone <br /> Address _. _ City jj., sQ <br /> Contractor Name c0 . License # f%%`'(,e) Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /'7 DESTRUCTION /7 4 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIQNS CIS <br /> Industrial Cable Tool Dia, of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing <br /> YDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> a_ Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done. <br /> ,DESTRUCTION OF WELL: Well Diameter �22, 'jPw +-�[� 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 �ili% E� f- c" TITLE rc l <br /> (DMA PLAT PLAN ON REVERSE SIDE) <br /> FOR DEPARTiBT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 4ROUT INSPECTION PHASE III FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BX DATE I6. 7% <br /> CALL FOR A GRO T INSPECTION PRIOR TO GROUTING,AND FINAL INSPECTION. . 01 <br /> E H 1426 7/72 1M <br /> ,1Y` "s ; - .�..v ',.fj. .^r: ::,,,,°�' xt; x ,. .y: r+Rr•:.. ..r o S.-,�f. <br />