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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j3_1� i AJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued U -L-7 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/LOCATIONJ p 3 J CENSUS TRACT <br /> Owner's Name -�o � - „ , ,f A p Phone <br /> y <br /> Address <br /> City <br /> Contractor's Name o License # I Phone71941 = 1� � <br /> TYPE OF WORK (Check): NEW WELL 'fj�j DEEPEN /_-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTAL TION / / PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other / / — — <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 lq �•t <br /> Domestic/private Drilled Dia. of Well Casing /A/7' S <br /> Domestic/public Driven Gauge of Casing <br /> r Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �•. <br /> Other Other Information <br /> h <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 <br /> (DRAW PLO PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II - OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 411ZIL <br /> DATE INSPECTION BY DATE/0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L H 1426 7/72 1M <br />