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✓ /!�� SAN JOAQUIN`-LOCAE HEALTH DISTRICT Y <br /> FOR�siiwz USE: 1601 E. Hazelton Ave.,-Stockton, Calif. <br /> Telephone: (209): 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J3-_2S'7l) <br /> R THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 �r� tG Www,' uit (Complete in Triplicate) <br /> Application Ys`hereby to the• Sin Joaquin Local Health District for A permiE 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 ADDRESS/LOCATION UJO /v" CENSUS TRACT 2 c_.C170-W; <br /> ;; <br /> ,,p Y 1 <br /> Owners Name &4a4 -o . . . .. .Phone <br /> Address <br /> Contractor's Name naIjAh License li 12o72_ Phone _,3L-9d z) <br /> TYPE OF WORK (Check): NEW WELL /,r/ DEEPEN /% RECONDITION /7 DESTRUCTION /7 3 <br /> PUMP INSTLATION /J PUMP REPAIR /% PUMP REPLACEMENT /7 4 <br /> Other / / <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 1y k fu L <br /> Domestic/public Driven Gauge of Casing /d Rjw <br /> Irrigations Gravel Pack Depth of Grout Seal ] <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor (y <br /> Type of Pump H.P. <br /> j PUMP REPLACEMENT: / / State Work Done <br /> i PUMP REPAIR: /% State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter - —^—'Approximate Depth <br /> Describe Material and Procedure <br /> I herebylagree 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ii GROUT INSPECTION PHASF I I F NAL INSPECTION <br /> 0SPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION..PRIOR...TO .GROUTING AND FINAL INSPECTION. <br /> I E H 1426 7/72 1M STt <br />