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r SAN .h)A,QUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�,.5_.3 37FJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ ,3:z <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 03 4 # CENSUS TRACT '2-0S- ltGo_07 i <br /> Owner's Name Phone ' 77 <br /> Address / �(� City <br /> n <br /> Contractor's Name License 46 IJ6 74 [ Phone <br /> O � <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_� RECONDITION Jam. DESTRUCTION /_7 CIP <br /> � F <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / -4- <br /> DISTANCE TO NEAREST: SEPTIC TANK $0.0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL1 CONSTRUCTION SPECIFIC;;i4 <br /> - Industrial ---y Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0.QgeL, <br /> Irrigation Grave-1 Pack Depth of Grout Seal 46:12 <br /> Other ;14 Rotary Type of Grout <br /> -_-- -- -- -- Other Other Information <br /> PUMP INSTALLATION: Contractor ; M <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 /> i <br /> SIGNED TITLE <br /> I <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -74 3/= <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSVECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 2Z ? INSPECTION BY DATE <br /> CALL FOR A GRO4 INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 7/72 IM f <br />