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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. 72-1861 <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -4-,?-72 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to Wnstruct <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 /> . � <br /> .... - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ,a >✓ `. ..� ' :n„�. 'k - Phone 3 _ <br /> Address ; City �,, � <br /> Contractor's Name 13 .1fi:1 P License !r Phone S <br /> TYPE OF WORK (Check): +NEW WELL DEEPEN / �/~ RECONDITION /�T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other &-Jn,. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER tIN9S PIT PRIVY d <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> r Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout F <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 <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 TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR MENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, III .FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ' DATE G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E ?/72 1M <br /> H 1426 <br />