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j SAN JOAQUIN LOCAL HtALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> OTT <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 /> (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 /> o- <br /> JOB ADDRESS/LOCATION as'a2 AGI CENSUS TRACT - <br /> Owner t s Name - <br /> ' � �' /i _f Phone <br /> r l cL 6rr _ - - - / <br /> ,�scit <br /> Address /�? +�vr. Sam � y - <br /> Contractor's Name : License I ��hone ylj�,Z -741 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /_/ RECONDITION /� DESTRUCTION /� <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 /> INTENDED USE TYPE' OF. WELL "-CONSTRUCTION SPECIFICATIONS V <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 /> 5 <br /> f <br /> PUMP INSTALLATION: Contractor VA -a-.- <br /> Type of Pump k H.P. / <br /> I, <br /> PUMP T: State Work Done .=. ,—oy�4VI c� ----- -- - - -- <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 S� <br /> g" ,� , r" h ITLE <br /> (D OT PLAN ON REV&RSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: LZZ <br /> PHASE II GR E TI PHASE II/FINAL, INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M u <br />