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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone : (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> if Date Issued <br /> If (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 worklherein 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 , <br /> 2 CENSUS TRACT J S <br /> Owner's Name JOIYN 0 <br /> ./' 7-7 <br /> Phone <br /> Address CIO �'r A%/b Y /J L JY r T . 0 <br /> II City IUTA&Ee-: A <br /> Contractor's Name <br /> VVI 4 '7 Cd/f C(d. License # 7L L�2 Phone i/62 j-597 <br /> TYPE OF WORK (Check): NEW WELL /i DEEPEN /? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PU14P REPAIR / / PUMP REPLACEMENT /-7 , .. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY t <br /> x CESSPOOL/SEEPAGE PIT - OTHER , <br /> INTENDED USE ji TYPE OF WE <br /> IndustriaLL CONSTRUCTION SPECIFICATIONS <br /> l Cable Tool Dia. of Well Excavation + <br /> Domestic/private Drilled Di '2 "} <br /> Domestic a. of Well, Casing � <br /> /public J Driven Gauge of -Casing <br /> Irrigation -=- - Gravel Pack Depth of Grout--Sealy- -- <br /> Other -- <br /> ._ Rotary Type of Grout <br /> Other Other Information _ <br /> Ch <br /> PUMP INSTALLATIONp" <br /> Contractor <br /> Type of Pump <br /> I! H.P. <br /> /, - <br /> PUMP REPLACEMENT: / / State Work Done !w. ~*O. <br /> i� <br /> PUMP REPAIR: State Work Done <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth 1 <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining, to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <br /> TELL DRILLERS REPORT of tie well and notify them before putting the well in use. ' The above <br />.nformation is true to thebest of. my. knowledge and belief.cl <br /> j <br />'SIGNED <br /> TITLE <br /> (DRAW .PLOT PLAN ON REVERSE SIDE 4 � i <br /> FOR DEPARTMENT USE ONLY <br /> RASE I 4 <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: p - _ ATE- -' <br /> PHASE IT GROUT INSPECTION P ' E' II INSPECTION <br /> NSPECTION BY it DATE <br /> INSPECT I-0N <br /> DATE — ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 � 7/72 1M <br />