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SAN JOAQUIN LOCAL HEALTH DISTRICT A�-Ct(Lf 113 <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -y� <br /> THISPERMIT 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 ADDREsS/LOCATIONS G� A / /-)IVC'/ ;p cENsus TRACT <br /> Owner t s Name % _0- A2 Phone F3%~ <br /> Address Jr-�3 Q city -'37 f Q/ <br /> Contractor's Name I//P. CG License #i 24,1.aZ Phone YGZ--SSJ, <br /> TYPE OF WORK (Check): NEW WELL IS DEEPEN /7 RECONDITION /-7 DESTRUCTION /"7 <br /> PUMP INSTAL LATION /-7 PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER Col, <br /> INTENDED USE TYPE.OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation IQ <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing _ 1 <br /> Irrigation Gravel Pack Depth of Grout Seal ( <br /> Other -- Rotary Type of Grout C4 j3 y <br /> Other Other InformationNC'- T Y 0 <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 <br /> . . ....„ .. - - --•--- Rerth <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 istrue to the best of my knowledge and belief. <br /> SIGNED / TITLE <br /> to's gDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY LL � "�-� <br /> DATE � ;z a <br /> ADDITION COMMENTS: <br /> PE II GROUT IN ON PHAS 444MAL I ECTIO <br /> Iqy <br /> ON r/r TIE INSEEC ON BY <br /> F'OR AROUTPEP I0 03W(, D FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />