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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI 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 -L ' -� 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/ ATION �.,, � 1� 0 � CENSUS TRACT <br /> Owner's N An *77 S Phone <br /> Address o�/ -7 S R46�� City art <br /> Contractor's Name � 0!/ it—joz!; License # e' 2y.-7�7� <br /> y. 'ghone <br /> TYPE OF WORK (Check): NEW WELL / j DEEPEN /-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '- PUMP REPLACEMENT /_77 <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 y� <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 Ole <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: State Work Done <br /> jDESTRUCTION 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 m owledge-an elief. <br /> SIGNE , , <br /> LE l <br /> RAW P ON EMPERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "^ DATE ---, : <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I NAL Il3SPECTION <br /> INSPECTION BY DATE INSPECTION BY 4kLt2 � u DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />