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F� 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.. -_2.2�� <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 17. $ i S CENSUS TRA44 7S 4<1 <br /> Owners Name L 5�t! , e Phone �- <br /> 4 <br /> Address �'T" City <6 N <br /> Contractor's Name .-V 1t 04WCLicense # -=I% Thone 4463Z/a <br /> TYPE OF WORK (Check) : NEW WELL xe/DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKACVSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _tQo_:f OTHER fft% <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI TIONS Tj <br /> Industrial X Cable Tool Dia. of Well Excavation T <br /> Domestic/private Drilled Dia. of Well CasingIf %ADomestic/public Driven Gauge of Casing _ . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 040 <br /> Other ..,.. � <br /> Rotary Type of Grout .SdZ <br /> Other Other Information AND <br /> PUMP INSTALLATION: Contractor .� ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1 <br /> State' Work Done <br /> PUMP REPAIR: <br /> / 1 State Work Done <br /> ESTRUCTION 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 knowled and b lief. <br /> SIGNED 1Y ` TITLE <br /> (DRAW PLOT P AN REVERSE SIDE <br /> FOR DEPhRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � c Y DATE 1�` 7-3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE � INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />