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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OF CE USE:_. 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephoner (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .�tAI ' <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued <br /> (Complete In Triplicate) <br /> Local Health District for permit to construct <br /> Application is hereby made to the San Joaquin <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 a /o 1� 01 0"o- CENSUS TRACT 5 <br /> Owner's Name p G� i ,44 Phone <br /> Address -- City �. <br /> Contractor's Name 1 License # 1/7q217,1 Phone- <br /> i -( f; <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /7 DESTRUCTION /_ k <br /> PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT /7 I <br /> Other <br /> } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled,,,z Dia, of Well Casing ..� � <br /> f Domestic/public Driven l Gauge of Casing 45 r <br /> Irrigation Gravel Pack Depth of Grout Seal -_ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I _ j <br /> PUMP INSTALLATION. Contractor �x <br /> Type of Pump H.P. <br /> * � F <br /> PUMP REPLACEMENT: / /. . State,".-Work Done I <br /> _ , -4 <br /> PUMP REPAIR: / / State- Work -Done i <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i - <br /> I hereby agree to comply with all'+1aws 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._REP-ORT_of-.nthe.�well-and-notif-y-_th&ni before.-put ting-the-we11 in-use:--The---above— <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDTITLElt <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - /�7 -- <br /> 'PHASE I DATEr-/`/ 7-- ,3 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 2 <br /> v " <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />