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w it_ reel 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 No. , !f y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Lzz-7�p <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 701*' � CENSUS'TRACT' 57 <br /> Owner s Name Phone <br /> Address �!1 ' . ' _ ' � `. City <br /> Contractor's Name _ �,� a License # Phone <br /> TYPE ,OF_.WQRK -(.Check) : NEW WELL / I DEEPEN /_/ RECONDITION DESTRUCTION-/ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / 7 <br /> -Other /_7 <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 />'t Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> f // • <br /> PUMP INSTALLATION: Contractor 45; ..c�i► <br /> Type of Pump H.P. <br /> k PUMP REPLACEMENT: / / State Work Done; _ Lj <br /> i PUMP REPAIR: / / State Word Done } <br />+ ,DESTRUCTION OF WELL: Well Diameter _ Approximate Depth F <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 ue to the best of my knowledge and belief. ; <br /> SIGNED TITLE <br /> i (DRAW PLOT..PLAN_ ON REVERSE SIDE <br /> OR D P TMENT USE ONLY <br /> PHASE I -� <br /> APPLICATION ACCEPT DATE /� 2-4 "Z3 <br /> j DITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION, • PHASE I I./FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BYE' DATE 0, <br /> 5 <br /> CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />