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SAN JOAQUIN LOCAL HEALTH DISTRICT �,S S <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. alo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CAAW `j' I»e10 &#rot -Ad -2 f f*7 W CENSUS TRACT <br /> Owner's Name A ro n �P, cam, ,' Phone <br /> Address __ ] A-L �_7ra4 e( City Lr/e fUe+_ <br /> Contractor's Name � ei / "" „7 License # /,�77,4'Phone V,611- 7424 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN j / RECONDITION /_ DESTRUCTION /-j <br /> PUMP INSTALLATION j / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFTCATTONS <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 /> Other Other Information • <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump K r` h 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 knowl,,edgg and belief. <br /> SIGNED �( 4.1 <br /> TITLE x_ ✓G1'. <br /> ( WPLOT PLAN ON VERSE SIDE�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPG T— <br /> E H 1426 7/72 1M <br />