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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V'OR OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z &.,c� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued !- ZY <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name a- Phone <br /> Address 17 Z-4 �;G _44in ei p 44 q Ito( City <br /> Contractor's Name I License # / hone ,L,/y <br /> E P <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP� INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I)_e7 <br /> i Other <br /> i � T <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 01 <br /> Domestic/private Drilled Dia. of Well Casing -C <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack "Depth `of GrdUt--Seal <br /> Other � ,( �a,u�n Rotary Type of Grout <br /> Other Other Information 0 <br /> k S <br /> G� <br /> PUMP INSTALLATION: Contractor <br /> Type l o f Pump R H.P. <br /> PUMP REPLACEMENT: /$7 State Work Done P-41// ��/,,� � , ,_,,� A�rr. � �� 1,74 <br /> PUMP REPAIR: / / % 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 completion-of my wor '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 kno edge and'b��ief. <br /> 6: <br /> SIGNED <br /> iV pr (DRA P T PLAN ON REVER �IDET <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY N*.`J3.11-- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT19. <br /> E H 1426 7/72 1M �� <br />