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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 PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-2 y I3 <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 �T�"� T CENSUS TRACT <br /> Owner's Name .- _Ptl_ l -- _Q 1` - - _ Phoney <br /> Address ZI.� , /�/�ays� City <br /> Contractor's Name � .ti a-�� ^ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL f J DEEPEN /_% RECONDITION /- DESTRUCTION / `— <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 F/1 <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 /> : r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - - - H.P. <br /> 1. <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP: REPAIR. /% State Work Done <br /> — I <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure--.--- J <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, 1 will furnish the San Joaquin Local Health District a <br /> E WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is t ue to the besrof y'knowledge and belief. �{ <br /> SIGNED b TITLE <br /> (DMY PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT- USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY E k <br /> ADDITIONAL COMMENTS: <br /> 3 PHASE II G SP&AON PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 7/72 1M <br />