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r <br /> 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. 7�-39Z lc/ <br /> /THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued L 7-7 <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 X1?)2RESS/LOCATION r ' O,C ©,j nuc N�sUsTRACT <br /> Owner's Name <br /> AL- 1=e� l2 Phone <br /> Address IVA <br /> City <br /> Contractor's Name ��iltil,Os License` �f flla9/ Phone 9--?T�3 <br /> TYPE OF WORK (Check) : NEW WELL.4,;�r DEEPEN /_% RECONDITION /_7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION.� PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL +� CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Er Cable Tool Dia. of Well Excavation <br /> ,r Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing A9 <br /> t <br /> Irrigation Gravel Pack Depth of Grout Seal _692 s <br /> Other Rotary Type of Grout ir1 <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor (l <br /> Type of Pump H.P. G <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - - <br />,PEST_RUCTION 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 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 _ TITLE C4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR 'DEPARTMENT USE ONLY i <br /> PHASE I i <br /> APPLICATION ACCEPTED BY f DATE <br /> .ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIFINAL INSPECTION <br /> � <br /> INSPECTION BY DATE =7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M c <br />