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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ,[ ,�jJ (e7- X70 -o( <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.. 3862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS AOCATION �v �� �-✓ '' � r?M l�J�r1.tr,e% r4 �ns n CENSUS TRACT <br /> Owner's Name IC-) L G_r Phone V-7r7 -- /`a <br /> Address S`� d _A-11 City QS'��s cG h <br /> Contractor's Name License 41 SI--Phoned-7G7 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN %/ RECONDITION /� DESTRUCTION // <br /> PUMP INSTALLATION / / PUMP REPAIR ICI PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> INTENDED USE 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 + i1 � <br /> ,�X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information I <br /> i <br /> PUMP INSTALLATION*. Contractor <br /> Type of Pump _H P. �U <br /> _ <br /> PUMP REPLACEMENT: / / State Work-Don-e c <br /> PUMP REPAIR: / / State Work Done -RA& ie„,nt <br /> ESTRUCTION 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 /> k 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 bes- -.Qf my knowledge and belief. <br /> SIGN D iTLE <br /> (Di2A� PL T PLAN ON . FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTIONPHA I F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BX DATE Q <br /> CALL FOR A GROUT.INSPECTION 'PRIOR TO GROUTING AND FINAL INSPEC N. 7/72 IM <br /> E H 1426 <br />