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oSAN JOAQUIN LOCAL; HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone! (209) 466--6781 <br /> APPLICATION FOR WELLCONSTkUCTION OR PUMP PERMIT Permit No. .3 -3 7i--- <br /> THIS PERMIT EXPIRES 1 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 Regulations of the San Joaquin Local. Health District. <br /> _JOB ADDRESS/LOCATION sp CENSUS TRACT <br /> Owner's Name /14 EL L_ Phone <br /> Address 7 S' City S 7"Orm <br /> a <br /> Contractor's Name License #_zPhone f✓71 � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _7p • 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 G" <br /> �X Domestic/private Drilled Dia. of Well Casing �^ <br /> - Domestic/public Driven Gauge of Casing /z <br /> Irrigation Gravel Pack Depth of Grout Seal ro. O� <br /> Other �_ Rotary Type of Grout CLQ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> S <br /> Type of Pump H.P. 2- <br /> PUMP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done - Y <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 my knowledge and belief. <br /> SIGNED TITLE <br /> (DIrAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT AE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 'f PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �dPI`FSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br />