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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. <br /> THIS PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made tothe 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 andtthe Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Q`alr�n- �l�>_ _CJ- NT1�l _ CENSUS TRACT z^2: <br /> Owner's Name ['Cf)SS - - Phone d <br /> 7S� <br /> Address 07 4-bLrifrcr�ct, City LA HAQUE <br /> Contractor's Name aA*A License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /'7 <br /> PUMP INSTALLATION /—/ 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 N-1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. I'I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: AU State Work Done � �r �f}2�. -•--• <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 1d TITLE aF <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i APPLICATION ACCEPTED BY DATE �� 'l'3 <br /> ADDITIONAL COMMENTS: `r <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION r <br /> d INSPECTION BY DATE ".:INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI N. <br /> E H 1426 7/72 1M <br />