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V SAN JOAQUIN 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. 7_i 1,,2 o2� ' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3- - —2 <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 SIS S`9 J¢� c4 (j.)t CENSUS TRACT <br /> Owner's Name NL t /C-e �'—CL (,I s Y` Phone <br /> Address _ — s� ---- — c c /tle - - City S�G c f <br /> Contractor's Name(. License #le Phone Ael—Z + <br /> E <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <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 /> s ' <br /> — <br /> Type of Pump H.P. <br /> _ 1 <br />` PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done /4 <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f 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 /> iinformation is true to the be of my knowledge and belief. <br /> �I z 0 t <br />� SIGNED: ITLE <br /> (� (DRA PLOT PLAN ON VERSE SIDE <br /> FO DEPARTMENT USE ONLY <br />� PHASE I � <br /> APPLICATION ACCEPTED B i <br /> DATED <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .. i <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL INSPECTION, 17 <br /> E H 1426 7/72 1M <br />