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SAN .70AQUI ti A "HEALTH DISTRICT -t►Lko -� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No.', 3_q0 eJ <br /> THIS"PERMIT EXPIRES-1-YEAR, FROM DATE ISSUED Dace Issued W,-i 4 <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/LOCATION <br /> ` ENSUS TRACT' <br /> Owner's Name '1t "° � .G.L► ...•......- -- - Phone .'" <br />-;;Address,- r City <br /> Contractor's Nameado License # )2-J;7244 Phone �C3�--•? ?y <br /> I <br /> TYPE OF WORK (Check) : NEW WELL /.T DEEPEN / / RECONDITION % ` DESTRUCTION '/- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br />• �Vj <br /> DISTANCE,,TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br />.x <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 tGravel Pack Depth of Grout Seal <br /> Other 'Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION-. Contractor <br /> I� Type of Pump H.P. . <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> r PUMP REPAIR: <br /> / / State Work Done <br /> i ESTRUCTION 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: . 19:�; � . I <br /> PRASE II GROUT INSPECTION. PHJ(KIWPIjrAL INSPECTIO <br /> INSPECTION BY ., DATE INSPECT BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING.AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />