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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POR 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. 3 <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 CENSUS TRACT cs�� <br /> Owner's Name Phone �,Xe /4� <br /> s ted�C <br /> Address �Z..__ City <br /> • Contractor's Name � , <br /> t License # W%V Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Othj_ .a2W <br /> e / <br /> DISTANCE TO NEAREST: SEPTiC TANK SEWER LINES PIT PRI <br /> SEWAGE DISPOSAL FIELD_ CESSPOOL/SEEPAGE PIT OTHER <br /> s TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE, hM o <br /> Industrial Cable Tool Dia. -of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout'Seal <br /> Other Rotary Type of Grout <br /> xOther VY �ryr [ + Other Information <br /> f <br /> PUMP INSTALLATION: Contractor &t_4� djLt <br /> Type o u ' VY H.P. 'Z. <br /> t <br /> PUMP REPLACEMENT: / State Work Done i <br /> PUMP REPAIR: / / State Work Done r <br /> PESTRUCTION_ OF WELL: Well Diameter /off Approxi ate pth �- <br /> Describe Material and Pr cedure <br /> I hereby agree to comply with all laws and regulations of the 5 n 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 f TITLEC <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE P '3D ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' D- +3 <br /> CALL FOR A GROUT INSPECTION PRIOR TOOUTING AND INAL NSPECTIO�. ` <br /> E..H 1426 �� � 7 7/72 1M <br />