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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. 12--'7Y5 <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 !-/ Q CENSUS TRACT <br /> Owner's Name <br /> . �.1t*t 1� ►.,.. _._.1 -],,,,,...a_Aan At $1 _o ...... Phone <br /> Address �J �("� C_ 2tt1 �! ' .,_ Cityp ~ <br /> Contractor's Name _rdrJ ,� License # X37+-hone � � <br /> IV <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR Jg/ PUMP REPLACEMENT /7 <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 /> .,._ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump e- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. 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 k owl a and belief. <br /> ti <br /> SIGNED TITLE <br /> ( IRAV PEOT PLAN ON Q&VERSE SIDE <br /> PHASE I FOR DEPARTtENZ USE ONLY <br /> APPLICATION ACCEPTED BYY",Oe- <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> 4e-r L-11 - 1 42 -12 2- <br /> PHASE II GROUT INSPECTION PHA I� AL INSPECTION <br /> INSPECTION BY DATE INSPECTIONBY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS I <br /> E H 1426 7/72 1 <br />