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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 /> AjaVaUAPICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. x.23 <br /> je <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,Heal:th District. <br /> JOB ADDRESS/LOCATION 1211 <br /> CENSUS TRACT <br /> Owner's Name <br /> .s CC e2 Phone <br /> Address City #4ea #, <br /> Contractor's Name " License # / --'hone G 2--74/0 ?� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN RECONDITION /- DESTRUCTION /-7PUMP INSTALLATION Y/ -7PUMP REPAIR / / PUMP REPLACEMENT /- <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 G <br /> IrrigationGravel Pack Depth of Grout Seal °rc� <br /> Other Rotary Type of Grout N <br /> Other Other Information <br /> � t <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. 3 <br /> State Work Done Of <br /> f "jam <br /> _ t <br /> PUMP REPAIR: <br /> / / State Work Done <br /> — <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 know dg e d belief. <br /> SIGNED t, <br /> � ITLE _ i <br /> ` W PLO PLAN ON R RSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS ,ECTION PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE <br /> CALL FOR A,-,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP T T_ <br /> E H 1426 7/72 1M <br />