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.0-,z SAN JOAQUIN LOCAL HEALTH DISTRICT -~ <br /> FOR 0 BICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 1z2..2-72 <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 <br /> CENSUS TRACT <br /> Owner's Name j] t p/ / Phone <br /> Address <br /> City <br /> Contractor's Name1 1. /{ License #2 0>Z10�-Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION —PUMP/ REPAIR / PUMP REP CEMENT /7 <br /> Other / / — <br /> �2 fl <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 /> dustrial Cable Tool Dia. of Well Excavation 40 4, <br /> Domestic/private Drilled Dia, of Well Casing , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />.RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> SIGNED <br /> �'e-nnkw <br /> TITLE PLOT PLAN ON REVERSE SIDE <br /> PHASE I F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: If <br /> PHASE II GROUT INSPECTION PHASE II FIN INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BYDATE _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEGTIO . <br /> E H 1426 <br /> 7/7z 1M <br />