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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 /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &1-1172- <br /> (Complete <br /> z(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. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> -- D� - L 1L1,�„!�_ Phone <br /> Address /77 - ...... --- CitySC �0� <br /> Contractor's ,Name License 4i 7790/p Phone V <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_` <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ~�- <br /> Domestic/private Drilled Dia, of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing n <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary 'Type of Grout V1 <br /> Other Other Information <br /> PUMP INSTALLATION: y Contxector ' yy <br /> Type of Pump 4 , H.P. e <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP REPAIR:= - - /State Work Donees <br /> ESTRUCTION OF WELL: Well Diameter <br /> �6 <br /> 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 ofr my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />. APPLICATION ACCEPTED BY DATE ��3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I INAL iN$PEC N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTI EC .t1N. , <br /> E H 1426 7/72 3M ' <br />