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J cid c'N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 :. Hazelton Ave. , Stockton, Cai�w . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a ��73 <br /> (Complete In Triplicate) t`r <br /> Application is hereby made to the San Joaquin Local Health District for E t construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /,� CENSUS TRACT <br /> qp,, 5�1 <br /> Owner's Name _r �2% $Sq/ <br /> Phone <br /> J <br /> Address b9Lt <br /> City <br /> Contractor's Name License #/ Phone T?�� <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR W PUMP REPLACEMENT /-7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSt FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> JyL ,?�m' (Ll�f�1/ C <br /> INTENDED USE V 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 /> PUMP INSTALLATION: Contractor <br /> iE , <br /> Type of Pump H.P. O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done t <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 them before putting the well in use. The above <br /> information i true to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ) �,/ <br /> APPLICATION ACCEPTED BY J �t '/l DATE 7.3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY-_ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W <br /> E H 1426 1 7/72 1M <br />