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.� l a . <br /> F . --SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:. '' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued -3 <br /> (Complete In Triplicate) <br /> Application is hereby shade 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 Joaqui <br /> County Ordinance No. 1862 a nth Ruses, ,n { e ulaattions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � z,� _ ��� _--- _ _ CENSUS TRACT <br /> Owner's Name Phone <br /> Address Z20 0 City <br /> Contractor's Name , jam ��, —� License # jg.323 Phone <br /> TYPE OF WORK-(Check)-; NEW-WELL /7 DEEPEN /_/- RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR/. / PUNY REPLACEMENT /? <br /> Other /_7 <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ; <br /> Other Rotary Type of Grout <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 /> ,pESTRUCTION 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 shy 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 �[ ,s, �,� -]YI l 11�. �•.G. J�et2CA o». .�-- --- TITLE �c�� ,ye�._G �7 �.-r <br /> (DRAW PLO LAN ON REVERSE SIDE) IV <br /> ,FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e ayY' _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, IIIJEINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> E H 1426 4/72 1M . <br /> a <br />