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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE S : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> id'Pe <br /> ATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. 7.2 '9<O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 �1� �� r` - .- CENSUS TRACT <br /> Owner's Name ,1,� Phone <br /> g <br /> Address 19dCity <br /> Contractor's Name License #`JQZhone 61 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN%/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION J / PUMP REPAIR J J 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 OI <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 ---V Rotary Type of Grout <br /> Other Other Information <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> — <br /> PUMP REPLACEMENT: J / 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .�--�j FOR DEPARTMENT USE ONLY <br /> PHASE I l P_ <br /> APPLICATION ACCEPTED BY g l3" DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 1d- -71, INSPECTION BY j1,7, DATE lo-#-7j.- <br /> CALL <br /> O-#-7zCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />