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SAN JpAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE- USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> lTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 trade in compliance with San Joaquin <br /> County Ordinance No. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (� 7 „•.. vut�- Q CENSUS TRACT <br /> Owners Name J <br /> ' �� l-�.t' � rf^'6 ti-I- --- --'-- Phone <br /> Address <S _ - - - - City Zscigza.e -- <br /> Contractor's Name d�� License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION '/7 DESTRUCTION /7 <br /> PUMP I INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE:PIT OTHER <br /> INTENDED USE TYPE OF WELL CCONSTRUCTION SPECIFICATIONS <br /> Industrial t r. Cable Tool Dia. of.-Well Excavation' " O� <br /> Domestic/private t Drilled Dia. of-Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �. ...-,1. _.....___Gravel..P.ack_... Depth of .Grout .Seal <br /> Other [ Rotary Type of Grout <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> stI <br /> } ti 1►G,�,Jv / G/ 1916 k':ifs <br /> PUMP REPLACEMENT: IS tate Work' Done <br /> !44-FUle-REPAIR. " <br /> : .RESTRUCTION-OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure' <br /> Y agree to comply� I hereb a with all laws and regulationsfof the San Joaquin Local Health District <br /> p Y <br /> j and the State of Californiapertaining to-or regulating.-well construction. - Within FIFTEEN DAYS <br /> I 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 12 TITLE o <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `TE 'I 3 <br /> ADDITIONAL COMMENTS: LIZ <br /> PHASE II GROUT INSPECTION P S /I I ALS INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY V4pATE 17 <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INS ECTION. <br /> E H 1426' 7/72 1M(�6 <br />