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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &:Z--z2- <br /> (Complete <br /> /--z2(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 /��` ��n J c�yl o.�j CENSUS TRACT <br /> Owner's Name i -� V a Ny w tc i Phone <br />, Address I dr City IR <br /> �� �y,� cense � f�}Dl D one <br /> Contractor's Name i � _ LiPh ._ <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-j DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /Tj'-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 Li <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /Z/' State Work Done h�fhn�rFj�—� X71 ,`___ _ <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 t ue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /11-222-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION /T.HAJWINAL INSPECTION <br /> INSPECTION BY DATE I a DATE � ZL Z. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />