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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. ZY—I�4) <br /> THIS PERMIT EXPIRES l'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 Regulati6ns of the San'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION iCENSUS TRACT J" <br /> Owner's Name Phone <br /> Addxess T�..l - Cit 10 - <br /> Contractor's Name License I Phone k <br /> TYPE OF WORK (Check) : NEW WELL '/ rDEEPEN T7 RECONDITION /7 DESTRUCTION -/-27--_ <br /> PUMP INSTALLATION /7��UAP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK,CC SEWER L NES -,. PIT PRIVY fA# 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ,$` OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Tndustrial Cable Tool Dia. of Well Excavation 1 <br /> omestic/private Drilled Dia, of Well Casing CQ <br /> Domestic/public Driven Gauge of Casing _ _ /l 40 <br /> Irrigation Gravel Pack Depth of Grout Seal _ '4742 lit trjgjs� <br /> Other l�Rotary Type of Grouty�� <br /> , -rt_ <br /> Other Other Information ' Ca C, A-'T' Td4:P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump � i.�r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter /f Appiroxi6te Depth <br /> Describe Material and Procedure , <br /> =6_7_[-tom/T 6�/M 6y f W �Sv ge eEACF <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di ,trict <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEI 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 t best f m owled a and belief, <br /> Al2--r I N Vu P PI'' <br /> SIGNED TITLE <br /> D OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPT ;GjUT <br /> R' DATE j <br /> ADDITIONAL CO <br /> P I INSPECT P I / INAL INSPE TION <br /> INSPECTION DATE INSPE TION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />