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bmA JOAQUIN LOCAL HEALTH DISTRICT y <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone: (209) 466-6781 PERMITm` ;� 1 <br /> ,APPLICATION FOR <br /> WELL CONSTRUCTION OR PUMP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f Date issuedIL--3_D_1&2_ <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 hereintheRulesa <br /> sdThis Reguulationstofnthe is Sanein nJoaquipLocalewith S <br /> Health <br /> aan Joaquin <br /> n <br /> District. <br /> County Ordinance No. 1862 an <br /> JOB ADDRESS AOCATION ' ,0 CENSUS TRACT <br /> Phone 3 <br /> Owner's Name O � G <br /> Address a If L- L=& 16Z j City <br /> Contractor's Name �lg License VX4_r Phone 4 <br /> TYPE OF WORK (Check): 'NEW WELL /7 DEEPEN _� RECONDITION /L7 DESTRUCTION /_7 <br /> PUFF.' INSTALLATION IKPUMP REPAIR I I PUMP REPLACEMENT / <br /> Other <br /> SEPTIC TANK ` SEWER LINES � i <br /> DISTANCE T� NEAREST: PIT PRIVY .�. <br /> ! SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> 1 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 /> 3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done T <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 thein before- putting the well in use. They above <br /> information is true to the best of my knowledge and.belief. <br /> SIGNED /� -' .ca TITLE <br /> (DRAW PL LAN ON REVERSE SIDE . <br /> i FOR DEPARTMENT USE ONLY <br /> ,:,:PHASE I A E r--;j d•� <br /> APPLICATION ACCEPTED <br /> BY <br /> ADDITIONAL. COMMENTS: <br /> ' PHASE II GROUT INSPECTION P E I INSPE TION <br /> INSPECTION BY DATE INSPECTION BY DATE 7/ <br /> E CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP C 7/72 1M � <br /> E H 1426 <br />