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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 <br /> (� APPLICATION FOR WELL CONSTRiFCTIQN OR PUMP PERMIT Permit No.J <br /> THIS PERMIT-'EXPIRES i YEAR FRQM.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 /> anal/or installl the work herein described. This application .is made, iiii�compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulation's 'of the San- Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> III <br /> - CENSUS TRACT <br /> III 'r .. r+, r .. � - i .. . <br /> Owner's Name !II 'Phone`- <br /> Address I ` <br /> ._. .City <br /> , = •- _ :o= . . .7—a�L—.. <br /> Contractor's Namen ��L 1 flQv <br /> U License <br /> k - - e <br /> Phone <br /> TYPE OF WORK ICI Check): NEW WELL /. DEEPEN /_% RECONDITION /_% DESTRUCTION _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other <br /> i Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> .1� SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X -Cable Tool Dia. of Well Excavation' tl� <br /> Domestic/private Drilled Dia. of Well Casing ' 1 L. 0 <br /> Domestic/public Driven . Gauge of Casing <br /> X! Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary " Type of Grout <br /> �I Other Other Information <br /> PUMP INSTALLATIION* Contractor <br /> f, Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done ,\ <br />'PUMP-REPAIR: FT State Work Done <br />.2ESTRUCTION _OFF.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 Sf 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 ,' PORT 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 /> i <br /> SIGNED _ _ TITLE <br /> �G (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BYDATE — f� <br /> 2e A <br /> ADDITIONAL COMMENTS <br /> AASE II GROUT 'INSPECTION PHAS ' II FINAL INSPECTION <br /> INSPECTION BY 'gyp DATE INSPECTION BY �� ,�- DATE e,.-z - 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 '11! 7/72 1M V <br />