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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. iF(K <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued �a 3 <br /> (Compldte In Triplicate) <br />' Application is hereby"made to the-San Joaquin Local Health District for a permit to construct <br /> is <br /> and/or install the work herein hes RulesdandThis Regulationstofnthe Sanein JoaquinpLocalewith HealthSDistrict� <br /> County Ordinance No. 1862 and t <br /> sCENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> � <br /> Owner's Name Phone' / ^F <br /> � City <br /> Address ,(G2 1G A- 4s <br /> ' <br /> Contractor's Name License # Phone <br /> _�! �!?! VY�L,( '�'lf� Gp- -- L - <br /> } TYPE OF WORK (Check) : NEW WELL / / DEEPEN /V RECONDITION /_ _DESTRUCTION /_7 <br /> "PUMP'INSTALLATION / J P1jMP REPAIR /%; PUMP REPLACEMENT /� <br /> Other [_7 <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 d, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven i Gauge of Casing <br /> �--�� Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary ., ;�~ .Type of Grow[ <br /> E Other Other Information <br /> y Y <br /> I <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State -Work Done <br /> Approximate Depth <br /> ESTRUCTION OF WELL: Well Diameter ° <br /> t <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 true to the best of 'my: knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE "-I/ `� <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE (k_ <br /> INSPECTION BY '1\ 0.. DATE 0. - INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. 7/72,1,Ml 61;� <br /> E H 1426 <br />