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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V 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 116-173 <br /> �- (Complete .In Triplicate) <br /> Application is h�e&y 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/LOCATX0N X7 CENSUS TRACT 5 Y b <br /> Owner's Name j Phone <br /> Address1ZCity <br /> Contractor's Name 'cense #.2? honeYJ <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7 RECONDITION DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION/—/ PUMP REPAIR /SUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD SEWER <br /> PITOTHER <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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary ]� Type of Grout <br /> /o <br /> . ther � ----- Other Information d <br /> 0F .W <br /> PUMP INSTALLAT ON: Contractor <br /> �P <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 REPO of the well and notify them before putting the well in use. The above <br /> information isbrto the best of my knowledge and belief.-1111, <br /> 4 1 4 <br /> �/0 <br /> SIGNED TITLE <br /> (DRA <br /> PLOT PLAN ON RPYERSE SI <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />