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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. 7_z-!135 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7L <br /> (Complete In Triplicate) q Y7 y� <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 1 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION "°"'°'``' C7Y �f" ,�/ J CENSUS TRACT J <br /> f <br /> Owner's Name Phone ' <br /> Address PAJ 4 9 City <br /> Contractor's NameuQom, ,`�lr_�yl_. License (, Phone <br /> ff <br /> TYPE- OF WORK -(Check) : NEW WELL -/-7 DEEPEN /� RECONDITION /? 'DESTRUCTION -/7-f f- <br /> PUMP INSTALLATION /—/ PUMP REPAIR . PUMP REPLACEMENT /- <br /> Other J / <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 X _ 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 fi <br /> 3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: MQ 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 TITLE , L .,�a r►e� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C, , DATE Z Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROAT INSPECTION PI/F#ALI14,0ECTION <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> --- - 1 GU. <br />