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SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOR OFFICE USE: ,'� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' fTelephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,2-//Q!� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 thCR'uulles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S " yN-1 %f z/, 7x—t °',l j.f CENSUS TRACT <br /> Owner's Name <br /> /T' � �-a'ktiL-D-�kar-a,d Phone � �- Q � <br /> Address f lJ L CI.G�fi� 'r City <br /> Contractor's Name License #/4.2-32,.?Phone <br /> TYPE OF WORK (Check): NEW WELL ,. DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC IONS � <br /> Industrial 3- Cable Tool Dia. of Well Excavation /a" /to r <br /> )K__ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /10 <br /> Irrigation Gravel Pack Depth of Grout Seal 15'O <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> b <br /> PUMP INSTALLATION: Contractor 10-10 <br /> Type of Pump �•-ti.{ H.P. 7 .i <br /> PUMP REPLACEMENT: State Work Done <br /> --v <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 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 o- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �Q 7 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II.G,_OUT INSP CTION PHASE IIjj?INAL INSPECTION _ <br /> INSPECTION BY ' DATE INSPECTION BY DATE :2-7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />