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JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q3-Z.-L�0 <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 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ) CENSUS TRACT <br /> Owner's Name Phone A_3S1?Q5-� <br /> nn � <br /> Ad,d e�� AG r City I <br /> Contractor's Name � License # Phone N <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_% RECONDITION /_� DESTRUCTION L,'�74F (1� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 aQ <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 <br /> Domestic/private `b( Drilled Dia. of Well Casing �- <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other )� Rotary Type of Grout <br /> Other Other Information "— <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> PUMP REPAIR: / / State Work Done s <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 /> informatio is true to t best of my knowledge and belief. t <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _L23 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPEC O PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 7/72 1M s <br />