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• T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OMICE USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> a Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT Permit. No. -13-15f (' <br /> R <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y —( - 3 <br /> (Complete In Triplicate) <br /> w 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 /> r } <br /> f. <br /> JOB ADDRESS/LOCATION j 1Z CENSUS TRACT <br /> Owner's Name _. _. Phone <br /> Address $G 17 7.f / �:- .. ..,__..__ ..-i City. <br /> Contractor's Name License # 373 Phone -925 <br />� I <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION /-7 w <br /> PUMP INSTALLATION / / PUMP REPAIR /S(/ PUMP REPLACEMENT /7 <br /> Other 1/7 <br /> DISTANCE TO NEAREST: SEPTICSEWER LINES PIT PRIVY r <br /> SEWAGE ,'D ISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> WAft r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private ! Drilled Dia, of Well Casing J <br /> Domestic/public I Driven Gauge of Casing , <br /> Irrigation 1 Gravel Pack Depth of Grout Seal ► ; <br /> Other Rotary Type of Grout {� <br /> Other Other Information • ', <br /> PUMP INSTALLATION: Contractor G <br /> Type of Pump - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP- REPAIR: / / -State Work Done <br />`.,pESTRUGTION OF WELL: Well Diameter _ <br /> Approximate -Depth �r <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 C' .� r. w TITLEI <br /> I {ORA LOT PLAN ON REVERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC ION PHASE I FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />