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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE.,USE: 1601 E. Hazelton Ave. , "Stockton, Calif. <br /> Telephone:. (209)' 466-6731 <br /> I PLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g�? <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date Issued �-& 7L <br /> (Complete In Triplicate) 2� - (X-to rd v <br /> Applicationjisaherebyf.madezto '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 OrdinancerNo:;1862-,andr.;the Rules and Regulations-of the San Joaquin Local Health District. <br /> 3-0.03 �°`�_�c►�.�:r:�c�c.: �� ..;�I,,/ <br /> JOB ADDRESS/LOCATION R baa { /✓ is�°�S4.414P '�.a1�- 40 ,' CENSUS TRACT <br /> LIJ <br /> Owner,`s Name'i .-v - Phone <br /> Address City t? <br /> k <br /> Contractor's Name License # / y Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> i PUMP INSTALLATION Y/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other,. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ry, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i - ( Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout, Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Conitr' dctor -4w // <br /> Type of Pump -- H.P. <br /> PUMP State Work Done �,+ d� <br /> s PUMP REPAIR: / / State Work Done <br /> j 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 ofknowle e an belief. <br /> SIGN 'D ITLE <br /> An <br /> RA PLOT AN ON WWRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '7_ <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL,INSPEGTION. <br /> E H 1426 4/72 1M <br />