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S.M. JOAQUIN LOCAL HEALTH 'DISTRICT <br /> ,F„DR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?—_ <br /> THIS PERMIT EXPIRES. 1 YEAR FROM-DATE ,-ISSUED Date Issued <br /> .3., (Complete In Triplicate) -II <br /> Application .is',-hereby! made oto, thecSan 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 �S. `i LL I S - -- CENSUS. TRACT ' <br /> Owner's Name'; �t► � . -rte 4,: Phone �U�l f Yz.�: <br /> Address S S ,�.� �.s.. .. . .. . ...City - <br /> Contractor's Name &. _ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN / T RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION _k/ PUMP REPAIR -/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS CD <br /> Industrial Cable Tool Dia. of Well Excavation til <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing n <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information �• <br /> PUMP INSTALLATION: Cir <br /> Type of Pump 9 G g _ H.F. I j� <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: J / 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 complet' n of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL S PORT of the we a notify them before.putting the well in use. The above <br /> informat n i true to the b t ' f my knowledge and belief, <br /> SIGNED TITLE <br /> 4 DRAW PLOT P AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q n <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ,',- PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY NIP, __ _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC N. _ <br /> E H 1426 f 4/72 1M <br />