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SAN JOAQUIN LOCAL HEALTH LISTRICT <br /> PFO!R]OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> y <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /� ] <br /> (Complete In Tripli ate) <br /> Application is hereby made to the San Joaquin Local Heal:h District for a permit to -construct <br /> and/or install the work herein described. This application is made in compliance with Sant Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Jr�`Lrr �� CENSUS TRACT <br /> Owner's Name Phone 92 3 5 ?;76 <br /> Address K. City <br /> Contractor's Name License # JQL73Phone ;,3, <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/_/ RECONDI TON /_7 DESTRUCTION /_7 <br /> PUMP INSTATION /' / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK./00 SEWER LINES PZX_PA F1-- <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 Ll <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout 's (cllltA� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor •-. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 c�'�v� ✓ TITLE7����'rLr <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 9,to - 9-2- INSPECTION BY G DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M �1 <br />