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SAN JOAQUI'N 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. ,Z5-' <br /> THIS PERMIT EXPIRES 1 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 /> 1"' <br /> JOB ADDRESS/LOCATION 1,0116 OVA .4el j�d� ' � <br /> Sa CENSUS TRACT Oaf—1!0--flS <br /> Owner's Name A Ak. ' Phone 1 <br /> Address city -�Cef&o <br /> Contractor's Name License # Phone <br /> TYPE OF-WORK (Check) -NEW-;WEL-L/��/"-DEEPEN /t/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / 'PUMP REPAIR / / PUMP REPLACEMENT /_XT <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 <br /> CONSTRUCTION SPECIFICATIONS • <br /> Industrial <br />_ Cable Tool Dia. of Well Excavation <br />)_ Domestic/private DrilledDia. of, Well Casing <br /> Domestic/public Driven Gauge of Casing aR <br /> -Irrigation Gravel Pack ,_Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 'Other Other Information (�1 <br /> PUMP INSTALLATION: Contractor 441 f <br /> Type of Pump h C H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> Y i <br /> PUMP REPAIR: / / State Work Done" <br /> ------------ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 <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- off my knowledge d belief. <br /> SIGNED f..� <br /> ��ITLE CCS ` <br /> PLO PLAN ON R ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY <br /> DATE `-3--� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />— E H 1426 7/72 1M <br />