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0" SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678I <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 12- 2Y.�7 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR,.FROM DATE ISSUED Date Issued 3/.1 v' <br /> (Complete In Triplicate) �7� <br /> Application is hereby made to the San Joaquin Local Health District for a perms 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 /> fZ35� S V A Al /?L�-. /� s� <br /> JOB ADDRESS/LOCATION �� CENSUS TRACT <br /> Owner's Name Phone -,2 <br /> Address City <br /> Contractor's Name / gbf S4`� <br /> Zicense �� , �. Phone 8'3jf.?i.�6 <br /> TYPE OF WORK (Check) : NEW WELL '/)Cj 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 <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing JgN <br /> Domestic/public Driven Gauge of Casing a 'Y'a— J&41 , <br /> Irrigation Gravel Pack Depth of Grout Seal y'L <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _ / / State Work Done_ <br /> DESTRUCTION OF WELL: Well Diameter '' Approximate Depth llG <br /> Describe Material and Procedure <br /> T0 ►l d 1�Pi.n B -AAA, <br /> ._ <br /> I hereby agree to comply with all laws and regula ions 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 04 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED,,BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIOZT I PHASE III/FINAL INSPECTJON <br /> INSPECTION BY 4U1 DATE — INSPECTION BY DATE —,;—/V <br /> FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �. 4/72 1M <br />