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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QFrICE USE: 1601 E. Hazeltdn 'Ave-. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 9l <br /> I <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3 S <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/LOCATIONV4��4zzly%-" = SAM Fa�— CENSUS TRACT <br /> Owner's Name V G Phone <br /> Address _ City <br /> i Contractor's NameLicense #a4fe9 one <br /> TYPE OF WORK (Check) : NEW WELL / / , DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ —PUMP REPAIR / / PUNK' REPLACEMENT /- <br /> f 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 /> N Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing _ - <br /> . Irrigation Gravel Pack Depth of Grout Seal ro <br /> Other Rotary Type of Grout <br /> Other Other Informat n <br /> Ll ZZ4 <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter 4 Approximate Depth c�d <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 aE- <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information s true to the best of my knowledge and belief, <br /> SIGNED - TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GR S PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 7/72 IM <br />