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11� <br /> v / • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFKCE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .. 267o S /i�11 <br />' JOB ADDRESS/LOCATION �{�,�/ �� CENSUS TRACT <br /> Owner's Name ('` - 'L 22 CR Phone �- <br /> AddressCn t � .�, '� � . 5 <br /> s;2,1 D._ i City <br /> 4 Contractor's Name a <br /> /P//.Z/�-SSS ��_( �ZL- License .# Phone <br /> f <br /> r TYPE OF WORK (Check): _x NEWT WELL /�f" DEEPEN / / RECOMI-i TION 7_7 -DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> other l/% <br /> DISTANCE TO NEAREST: SEPTIC 1TANK SEWER LINES PIT PRIVY I <br /> SEWAGE =DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia. of Well Excavation " f� <br /> Domestic/private t Drilled Dia. of Well Casing 51" <br /> Domestic/public ± Driven Gauge of Casing Q <br /> Irrigation �' Gravel Pack Depth of Grout Seal <br /> Other - Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> / / State Work Dane <br /> PUMP' REPAIR: 1 <br /> State Work Done <br /> .7ES_TRUCTIOR-& WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 t <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 est ojf my knowledge and belief. <br /> SIGNED - � <br /> -Y TITLE <br /> RA PLOT PLAN ON REVERSE SID-,E) 1 . <br /> PHASE I FOR DEPARTMENT USE ONLY f <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: -3/ <br /> PHASE II GROUT INSPECTION . PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION, BY DATE-- _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EY H 1426 7/72 1M <br /> r a <br />