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J-" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE�USE,: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> .APLTCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 5-lr1-7 L <br /> (Complete In Triplicate) <br /> Application is hereby maa 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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> N <br /> JOB ADDRESS/LOCATION f No vaf 14CENSUS TRACT <br /> Owner's Name M E�,�f1.lL �� �,l ,. _ Phone ' Rg8 � <br /> Address City JESC A ,r� <br /> Contractor's Name License # Phone SS-e2-20? <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN '/_/ RECONDITION /^T DESTRUCTION /-7 _ - <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q. <br /> Domestic/public Driven Gauge of Casing N <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout , <br /> Other Other Information ' <br /> PUMP INSTALLATION: ContractorLAL- <br /> �„ J <br /> Type of Pump S L-j H.P. <br /> PUMP REPLACEMENT: /State Work Done _eu—// 4P g 1fg /3-C& %,4&7.4 JAZ:tSsb <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 /> atter 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY s <br /> PHASE I (_.c/ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I4FIUAL INSPECTION F <br /> INSPECTION BY DATE � INSPECTION BY DATE :Zy <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. T <br /> E H 1426 4/72 1M k <br /> a <br />