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JOAQUIN LOCAL HEALTH DISTRIC*� <br /> FOR OFFICE USE: 16C _i. Hazelton Ave. , Stockton, Cal <br /> J <br /> Telephone: (209) 465-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />`. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-` _ 3 <br /> (Complete In Triplicate) D <br /> Application is hereby made to the San Joaquin Local Health District t construct <br /> and/or install the work herein described. This application is made in comp iance with San Joaquin. <br /> County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION Zj� La eta L n J Q`' CENSUS TRACT <br /> Owner f s Name _.r�►11 _ L----� ��2 Phone 19$a <br /> Address SZ3 kn 6-- City <br /> Contractor's NameW'% � �nl ; �J License Phone <br /> TYPE OF WORK (Check): NEW WELL / I DEEPEN /_/ RECONDITION /_� DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other 17 <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled 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 <br /> Other Other Information <br /> a <br /> j PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done % L�' <br /> f <br /> 1 PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 1 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 /> i information is true to the be t of my knowledge and belief. <br /> I SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE II 1 <br /> 1 ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 45 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1 E H1426 7/72 IM <br />