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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFt OFFICE USE: -1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR ,PUMP PERMIT Permit No. _gyp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued l -19 jz <br /> Application is hereby made t the San (Joaquin Local Health complete In tDistrict for a permitto construct, <br /> and/or install the worst herein described. This application is made in compliance with San Joaquin <br /> t 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 09 <br /> Phone <br /> Address r. <br /> City 0V,-- - <br /> t Contractor's Name <br /> License # ZPhone <br /> X12- v7 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /_/ RECONDITION /_7 DESTRUCTION_ _/7 <br /> PUMP INSTALLATION <br /> PUMP REPAIR /L/'PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TAMC A <br /> SEWER LINES PIT PRIVY ! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE OF 'WELL TYPE OF ble CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable To Dia, of Well Excavation <br /> Domestic/private ,- DrilledS <br /> Doruestic Dia. of Well Casing <br /> /public Driven Gauge of Casin <br /> Irrigation g <br /> Gravel Pack,..: Depth of Grout Seal <br /> Other:-; Rotary Type of Grout <br /> Other Other Information <br /> 3 <br /> PUMP INSTALLATION: Contractor <br /> ` Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />-PUMP-REPAIRP Sta W <br /> d7rk' DoneF- <br />,PESTRUCTION OF WELL: Well Diameter <br /> Describe,Material aad., Procedure Approximate Depth. <br /> I hereby agree to comply with;.all laws an ' 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 ona 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 be fi of my knowledge and belief. <br /> SIGNER } ; <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> e� <br /> PRASE IFOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATEL. /�/f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONP E I / NAL INSPECTION <br /> INSPECTION BY DATE INSPEC N <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 ' <br /> 7/72 1M C <br />