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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 -37L <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ) <br /> (Complete In Triplicate) <br /> Application is hereby Invade 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i JOB ADDRESS/LOCATION . � , � e CENSUS TRACT <br /> !. <br /> Owner's Name - �?� E _ �. � �G� Phone'EM— , <br /> y <br /> Address City <br /> sContractor's Name I� ref/I Aq Licensephone A <br /> � Q <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN ` RECONDITION e DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REP GEMENT <br /> Other / / /164 N <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 pIndustrial Cable Tool Dia, of Well Excavation <br /> i Domestic/private - - Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> r Other Rotary Type of Grout 4n <br /> I! Other Other Information <br /> PUMP INSTALLATION: Contractor yC �ftd1. JC <br /> Type of Pump o. H.P. �+ <br /> PUMP REPLACEMENT: State Work Done <br /> V <br /> PUMP REPAIR: �1/ / State Work Done <br /> ,DESTRUCTION OF. WELL: Ye 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 cam letion of myiGwork on a new well, I will furnish the San Joaquin Local Health District a <br /> ' WELL D LLE REPORT of the well and notify them before putting the well in use. The above <br /> informat i true tdthe best fmy knowledge and belief. <br /> SIGNED �,� _., TITLE <br /> i� (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �' J— <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 41 <br /> PHASE II GROUT INSPECTION - PHASE III/FINAL INSPECTION <br /> INSPECTION BY 'Z "f' _ _ <br /> t _ j.� DATE /P7-_?/-71 INSPECTION BY DATE <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> k E H 1426 7/72 1M <br />