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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 No. <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 CENSUS TRACT <br /> Owner's Naim' ,.- `pd (�- , n n.e.c i Cj(A �j Phone <br /> Address !K 4L3 / ASA A" �Qxs, City <br /> Contractor's Name < License # L Phone �y76 21. <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_� RECONDITION /-7 DESTRUCTION 1-7 <br /> AL <br /> PUMP INSTLATION /—/ 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 r.. <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 /> �),a Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Q H.P. - <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / State Work Done .jl , /(r �,k� 1 /, p. fk a[ 4-ce <br />,DESTRUCTION OF WELL: Well Diateeter �' ° .f'` / ''r r��f f �p�fjox3mat��pt`h` �� <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Heal � istrict <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 mom.-enow ed belief. <br /> SIGNED rX <br /> 4 4. ITLE <br /> P1 T PLAN ON REVERSE SIDE <br /> FOR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC I N P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 7/72 1M <br />