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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> s Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6-9// 0 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0OOn N' /4R p Tib CENSUS TRACT <br /> Owner's Name `� Phone <br /> Address Y"i 4-0 City <br /> Contractor's Name �� hd 12 License ��� 77 Phone <br /> TYPE OF WORK (Check): NEW WELL/, DEEPEN /7 RECONDITION /—[ DESTRUCTION /7 <br /> PUMP INSTALLATION 2/, 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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -��- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other )_ Rotary Type of Grout <br /> Other Other Information 1 <br /> PUMP INSTALLATION: Contractor <br /> f� <br /> Type of Pump H.P. <br /> .PUMP REPLACEMENT: / f State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DE°STRUCTION OF WELL: Well Diameter Approximate Depth 9� <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 4TLE I <br /> T <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FDR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASg/VI)i/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTh4l. <br /> E H 1426 4/72 1M <br />