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e 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. 1 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/`_Zr __71. <br /> E (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/LOCATYON 6L t-p,� jea top' n/ dry . CENSUS TRACT <br /> # j <br /> Owner-t s Name <br /> Phone <br /> Address _ �G���v � �� d-m O��� _,....___._ City <br /> Contractor's Name ' u License � 4y 7y,i--_Phone ' 1_„'767Z <br /> TYPE OF WORK (Check): , NEW WELL /7 DEEPEN / / RECONDITION /—T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY __3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS dpi <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing �f <br /> gL Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information _�J <br /> PUMP INSTALLATION* M Contractor <br /> Type of Pump t u Y tij e jrH.P. /,rf <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR, State Work Done �Pu ✓�s oa /off n� �6r1s x <br /> I <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 y knowledge and belief. <br /> SIGNED� ITLE �'�" <br /> D W PLOT PLAN ON RVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY i� DATE �a ADDITIONAL.-COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �/0'_ DATE INSPECTION BY TE <br /> r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />