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i <br /> 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.Z3- l 14 <br /> I <br /> THIS. PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued.3-a2 7 -3 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �,A�a r � CENSUS TRACT <br /> Owner's Name .5 . ,q ✓,� s -Phone <br /> Address L - L . t�c�o R a-� _ -if City <br /> Contractor's Namee License # H;7Z4 hone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT J� <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 WELLi � t <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing i <br /> Domestic/public i Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other- - Rotary Type of Grout S. <br /> _• '- Other Other Information Qr <br /> . . . _ c <br /> PUMP INSTALLATION: Contractor - f '. <br /> Type of Pump -ru i.�y V'_ <br /> H.P. f <br /> PUMP REPLACEMENT: / / -S'tate Work Done <br /> PUMP REPAIR: / / State Work Done <br /> j <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure y" <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 .weli and notify them before putting the well in use. The above <br /> informationistrue to the best of know ledge-and belief. ii <br /> SIGNEHP�0I c''7 �. TITLE.!', <br /> D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 ' <br /> 7/72 1M <br />