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`y _ �V) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> v 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 6._�p_7z <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/LOCATION CENSUS TRACT <br /> Owner's NamePh <br /> Phone <br /> Address 37W 6 City <br /> G-Ia . G-6r <br /> Contractor's Name License 41/2,&EM Phone ' J_- <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION f4' PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / ^' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERC��®j� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth Y <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 /> 1 <br /> SIGNED TITLEX,1�4 <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY ___-- <br /> PHASE I C s <br /> APPLICATION ACCEPTED BY DATE��.2 S^7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II FtAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />