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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 N o. <br /> 11;1� <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 Regulations1 of the San Joaquin Local Health District. <br /> -:2_ <br /> JOB ADDRESS/LOCATION S �,Z(."V-4 &""O� r4 - )?U& 4j, CENSUS TRACT <br /> Owner's Name q Phone l <br /> 6 �--o y— <br /> Address City <br /> rJ <br /> Contractor's Name License #/4�32-3Phone <br /> TYPE OF WORK (Check) : NEW WELL .; DEEPEN /—/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ —PUMP REPAIR REPLACEMENT— <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL <br /> FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC IONS <br /> Industrial )< Cable Tool Dia. of Well Excavation 1-1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 3P. <br /> Irrigation 0 <br /> Gravel Pack Depth of Grout Seal 10 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> tf <br /> PUMP INSTALLATION: Contractor )0,..-- <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: State Work Done <br />,PESTRUCTION 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 knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE C Q 7 Z -- <br /> ADDITIONAL COMMENTS: 4z <br /> PHASE II, G.IkOUT INSPECTION PHASE II;I/,FINAL INSPECTION <br /> INSPECTION BY <br /> DTTE " INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . --- <br /> E H 1426 7/72 1M <br />