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d SAN JOAQUIN LOCAL HEALTH DILICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '3 <br /> E (� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-J-7-3 <br /> � � (Complete In Triplicate) <br /> Applicatioi -is hereby de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work erein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,Ls� ��r zcrt x �� ,- � 1 h ' sjCENSUS TRACT <br /> Owner's Name Phone e <br /> Address <br /> Contractor's Nam - m / License Phone <br /> TYPE OF WORK (Check): NEW WELL LV DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <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 O <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 'Domestic/private _ X 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 <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 ( A.. ,._,J, (�Y� ci� TITLE / Z <br /> (DRAW PLOT PLAN ON REVERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE < � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTIO <br /> INSPECTION BY ' 4 DATE ,Z-- z %,: INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 7/72 1M <br />