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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 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> ar 4 7 , <br /> JOB ii8�6/LOCATION r �� _ ENSUS TRACT <br /> Owner's Name FJ� �� � � Phone �� - <br /> Address city ¢ <br /> F <br /> Contractor's Name5`1icensq-AV Phone ,�� % <br /> TYPE OF WORK (Check): NEW WELL /X/ DEEPEN /-7 RECONDITION /-T DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK _;S�7( SEW R LINES -=PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ��r?r G 98-b/SEEPAGE PI , OTHER /�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia, of Well Excavation 77_ <br /> Domestic/private ---,A- Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing _ <br /> r V 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 ._. �'r� L ' -A6��,e= H.P. >' >_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY ` DATE j -41-01 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />