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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.603. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: Q09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -)2---512,- <br /> THIS <br /> o. 7L-51LTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued (O_/•_ 7 <br /> (Complete In Triplicate) <br /> Application is hereby de 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 �4 9 � � �tmy � � G � CENSUS TRACT <br /> Owner's Name �jo@zj fQ Phone 9Y.?-0,5� ' <br /> Address 0.0f�,,,G 19`�- -- - City-. ict�+r.[� <br /> Contractor's Name ,� �,;iy J ,, License # Phone <br /> TYPE OF WORK (Check) : NEW WELL ./ / DEEPEN '/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /x/ PUMP REPLACEMENT /- <br /> Other /-7 <br /> F <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 /> 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 Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />" 10Um <br /> PUMP REPAIR: <br /> /)(/ State Work Done <br /> Ur <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> i <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 F'IFTEEIV 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 /> SIGNEDqk �y f j TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7-- <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIONBY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />