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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 V,-3y(Aj <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 hereb 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/LOCATION 41 11� p1�7 - CENSUS TRACT <br /> Owner's Name .70 A f C.,'.', e? Phone 9 I /_0? 4 <br /> Address 3 '-i tlVk'_ City <br /> Contractor's Name � ._. License #j 4 -c y Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_7 RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT- 1-7 <br /> Other /_7 —1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 6d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 s-o <br /> Other Rotary Type of Grout r � z <br /> Other Other Information Q. <br /> PUMP INSTALLATION: Contractor .� _ '4e x ._ f <br /> Type of Pump 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 � �, <br /> 7 TITLE Ltra�-rte , <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> PHASE I FO)( DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY gkt _i �ta4--6Z DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHAS INSPE TION <br /> INSPECTION BY DATE NSPECTION BY DATE - 0- <br /> CALL FOR A GROUT INSPECTION PRIOR TO G OUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />