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i "AN JOAQUIN LOCAL HEALTH DISTRIA"I <br /> FOR OFFICE USE: 16,._ E. Hazelton Ave. , Stockton, Calf. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1`s_ u t k{ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 L7 3 <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 /> JOB ADDRESS/LOCATION /C z;—/ C CENSUS TRACT <br /> -Owner's Nameif Phone <br /> a e l�ti �- c� Phone <br /> Address City <br /> :ontractor's Name J �� i L License # & hone �r7 f tfG <br /> 7"YPE OF WORK (Check) : NEW WELLDEEPEN /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other /-7 <br /> )ISTANCE 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 /y�` <br /> Domestic/public Driven Gauge of Casing AD, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout " <br /> Other Other Information ' <br /> i <br /> .PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> -9ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> -1 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 /> .nformationis true to the best of my knowledge and belief. <br /> SIGNED L W >� ` lg l ( �—v TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> -APPLICATION ACCEPTED BY DATE <br /> J)DITIONAL COMMENTS: <br /> PHASE II ' OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/n <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />