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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. �3 'L(. <br /> Z3 s'7 0- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (;� '-�O <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 ADDRESSjLOCATION jam' CENSUS TRACT <br /> Owner's Name ��) , ,Al-./� �3 Phone g -I—)z <br /> Address ��y, ff.�� .r� IIC City ��. � <br /> Contractor's Name _ ���i <`s� Jr�� License # Phone _ y <br /> TYPE OF WORK (Check): NEW WELL 4 DEEPEN -7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor t, <br /> Type of Pump H.P. _;�F <br /> PUMP REPLACEMENT: / / 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 <br /> TITLE <br /> (DRAW PEN PLAN ON REVERSE SIDE .` <br /> F9RVZPARTNENT USE ONLY <br /> PHASE I -' <br /> APPLICATION ACCEPTE BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASWJ GROUT INSPECTION P!YMII& AL INSPECTI <br /> INSPECTION BY DATE INSPECTI Y DATE Zg- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />