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T SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOX'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209)466--6781 <br /> APPLICATION FORWELLCONSTRUCTION OR PUMP PERMIT Permit No. 'o2-/JD 10 <br /> THIS PERMIT EXPIRES I. 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 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 sa �t �0 R 1 CENSUS TRACT <br /> Owner's NamePhone <br /> Address - � City <br /> Yy <br /> ' C/ <br /> �� -e'� License ,� , Phone <br /> Contractor's Name1 ) >' <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN i / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /-7 <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 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 W <br /> Other Rotary Type of Grout <br /> Other Other Information (►� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 7P <br /> PUMP REPLACEMENT: / j State Work Done RFIWOV= <br /> PUMP REPAIR: J / State Work Done R F- 5EJ}L C/4S f nJC, <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 bst of my knowledge and belief. <br /> SIGNED TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ,/' R �P TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE L�- - 7Z_. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INSPECTION <br /> INSPECTION BY TE INSPECTION BY U DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />