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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466=6781 <br /> LICATION FOR WELL CONSTRUCTION OR'PUMP PERMIT Permit No. '7) <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED' Date Issued.� `7�— <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 S (! CENSUS TRACT <br /> G > <br /> Owner's Name F <br /> Phone <br /> Addresst Ci <br /> y, <br /> Contractor's Name "-� <br /> '��= 1 License !E � .�) Phone ,�42S' <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_/ RECONDITION /_ TDESTRUCTION /'T <br /> AL <br /> PUMP INSTALLATION —PUMP PUMP REPAIR /�(/ PUMP REPLACEMENT /_ <br /> Other / / <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 Q <br /> . y Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP REPAIR: kT- /.-. State Work Done <br /> ESTRUCTION 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 /> 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 _E. ��� ���_� (.l' , 1 R TITLE <br /> (DRAW PLOT PAN ON REVERSE SIDE <br /> O <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT W&I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I IV FINAL INSPECTIO <br /> INSPECTION BY DATE. INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PR70R. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 7/72 1M C.�� <br />