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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP, OFFICE USE: 1601 E. HazeLton-Ave. , Stockton, Calif. <br /> Y, Telephone: (204) 466-6781 # <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- ,,,e � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6- L- 7� <br /> 612 .y=E.:'!� _,ZJ �- . j 1W (Complete In Triplicate) <br /> Application is hereby de 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 ,S�mcc 1_4 ry� S t-C. E CENSUS TRACT l 01-ZS0--09 <br /> Owner's Name /Alan <br /> Phone <br /> Address 6/®.Z 42 /{fir. City <br /> Contractor's Name J .G License # /B;7;-3 Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR �X/ PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> O � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial Cable Tool Dia. of Well Excavation } i <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> X - Irrigation Gravel Pack Depth of Grout Seal ; <br /> Other r Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Ir rte ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: =f State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure � <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Loc a1 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 m kii-owle5d!geand belief. <br /> SIGNED _ �, w TLE <br /> 'I� &Menl <br /> (D PLO PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHA III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM f <br />