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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-o-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,L- 28cP4-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- <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 <br /> JOB ADDRESS/LOCATION 77 7 ~: k7 22 Al CENSUS TRACT f ! <br /> Owner 1 s Nate ()&=" Phone <br /> Address °� ` <br /> City ���.,-• Gro, �. <br /> Contractor's Name License # 7 <br /> K( Phone j1,z 6',j' <br /> TYPE OF WORK (Check) : NEW WELL 97 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK j� ! <br /> .�, 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 ,2 _ <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gaugeof Casing _ <br /> IrGauge. <br /> of <br /> Gravel Pack Depth bf Grout Seals' <br /> Other Rotary Type of Grout __- --- ,4A l <br /> Other Other Information r <br /> PUMP INSTALLATION: Contractor _ <br /> Type -of -Pump <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—iq true to the best of my knowledge and belief. <br /> SIGNED '� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> _ FOR DEPARTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: _ <br /> P SE I ROUT INS EC ON PHAS I NAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />