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SAN JOAQUIN LOCAL HEALTH DISTRICT [ 9tq 3 3 <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. �j3-�{3 v� <br /> THIS PERMIT 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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z6.Sf�.S �1./V/� /V CENSUS TRACT <br /> Owner's Name if ft±JORSU 1 D0 —1AEE9&sQQJ I Phone <br /> Address / Z— - !VT �R� ��� - City <br /> Contractor's Name License # Phone <br /> — <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other: 17 _Se.�S� EX UA Lal E RD F_ <br /> DISTANCE TO NEAREST: SEPTIC TANK p"+ SEWER �INES + PIT PRIVY Nor- <br /> JE-SEWAGE DISPOSAL FIELD 50 4--'CESSPOOL/SEEPAGE PIT /I/ONF OTHER N17NE_ <br /> E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` A <br /> Industrial ;` Cable Tool Dia. of Well Ekeavation , '! <br /> Domestic/private D'rilled,,; Dia. of Well Casing <br /> Domestic/public Driven, Gauge of Casing <br /> Irrigation,,, _.. ; Gravel Pack Depth of Grout..Seal - - <br /> Other Rotary Type of Grout _ 60A/CRF-T� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> TYPe of Puiip H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> E. PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF=WELL: - Well Diameter Approximate Depth <br /> Describe Material and Procedur'e ._ <br /> I hereby agree- to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the StateofYCalifornia 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 potting the well' in use. The above <br /> information true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I <br /> APPLICATION!ACCEPTED Y t DATE -f - <br /> ADDITIONAL COMMENTS: <br /> '- 'PHASE-II GROUT INSPECTION INAL INSPEC N <br /> INSPECTION BY DATE 2�-��' INSP DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />