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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/4/ 2}1 <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 Joaquk <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION a- r CENSUS TRACT <br /> Owner's Name Ilill' 1111 III IIII10 <br /> / �a X a Phone <br /> :i <br /> Address J257boa City <br /> Contractor's Name ; 0 4 License #/jj2,l Phone C <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN RECONDITION /_ DESTRUCTION /_7 <br /> , PUMP INSTALLATION / / PUMP REPAIR <br /> Other /% �/ PUMP REPLACEMENT /? � <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> + SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private' Drilled Dia. of Well Casing <br /> Domestic/public IDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> - Other �� Rotary Type of Grout.. <br /> 1� Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / t.a1't H.P. " <br /> PUMP REPLACEMENT; / State Work Done <br /> I PUMP REPAIR: I State Work Done /tis <br /> 1M. <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 offthe well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge d. bel f. <br /> a <br /> SIGNED - - i . <br /> TLEGsf. - <br /> iE (DRAW OT ON RE SE SIDE <br /> PHASE I <br /> F EPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY, DATE --� ^-�/L--- <br /> ADDITIONAL COMMiNTS: ��' <br /> PRASE II GROUT INSPECTION PH&%e)JI_UZINAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE _/�_,pe)Zf <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' <br /> J: 7/72 1M <br />