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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7.1�yG w <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> k <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -�o_y_7a <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 ules and Regulations of the San Joaquin Local Health District: <br /> � 3 � <br /> JOB ADD S/LOCATION d �, <br /> A ,/ ENSUS TRACT S j <br /> Owner's Name 4 # :�� r - Phone <br /> Address C20 � _ _ k <br /> City � <br /> Contractor's Name t -�� <br /> - � � " License 1� Phone <br /> TYPE OF WORK (Check): NEW WELL 2W DEEPEN /_/ RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / F <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY <br /> SEWAGE )DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> —�- CONSTRUCTION SPECIFICATIONS <br /> _ Industrial �- Cable Tool Dia, of Well Excavation z a w <br /> Domestic/private Drilled Dia, of Well Casing •� <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,1'D <br /> Otherj� <br /> i -Rotary Type of Grout es <br /> Other Other Information <br /> � M <br /> PUMP INSTALLATION: Contra for <br /> Type of Pump • H.P. <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP REPAIR: _ State Work Done- <br /> ,DESTRUCTION <br /> one ESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply .withall 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 co letion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL-DR LL S REPORT of the well and notify them before putting the well in use. The above <br /> informat is true to the est of my knowledge and belief. <br /> _. 4 <br /> SIGNED �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> t FOR DEPARTMENT USE ONLY <br /> t w � <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION f <br /> INSPECTION BY DATE 1� �•2"✓ _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />