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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 /> APPLICATION FOR WELL CONSTRUCTION OR PL'',P PERMIT Permit No. - �W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> C Z .I (Complete in Triplicate) _ <br /> Application is hereby made to the San Joaquin Local Health District for �a g, <br /> tto c�onnstruct <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 .LJ ,1 d�.�0-/ / 7-� = CENSUS TRACT <br /> Owner's Name �2j�-F �' 'E- <br /> _p ! ' ' Phone / ` <br /> Address <br /> City <br /> Contractor's Name ,d- License #Ll <br /> 1/,?X73_ Phone 1��4L Z a� C <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPENS/f RECONDITION /-7 DESTRUCTION /-"- <br /> PUMP INSTALLATION /' / PUMP REPAIR / PUMP REPLACEMENT /- <br /> Other / / - � 4 T Lug�- �zo�• .�� �. � <br /> DISTANCE TO NEAREST: SEPTIC TANK—77O J SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERi <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 /> PUMP REPAIR: / / State Work Done <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 /> 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 2 G TITLE <br /> (DRAW PL PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY s <br /> APPLICATION ACCEPTED BY <br /> C " DATE 7-1�'��3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_ III FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BYDATE <br /> d <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72. 1M <br />