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^ r ' <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. .�L3 -7a� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�-/ <br /> (Complete In Triplicate) O5, r�L( �� ` <br /> Application 3s 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 r ! l �., � /%jam L� j �� !�_, ,_CENSUS TRACT <br /> Owner's Name ; ''l�j ' <br /> Phone ` r. <br /> Address — __22 , City <br /> r f,41 ,.. <br /> Contractor's Name License #16.),373 Phone <br />;TYPE ,OF WORK (Check) :,. NEW WELL /_7 DEEPEN/7 RECONDITION/-7• DESTRUCTION--/_7-- - tom, <br /> PUMP INSTALLATION / / PITMP REPAIR J PUMP REPLACEMENT /7 v <br /> Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANKa _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED-USE-:- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial_ 11 Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled. Dia. of Well Casing A <br /> Domestic/public '1 Driven, Gauge of Casing <br />�� Irrigation Gravel Pack Depth of Grout Seal 4 k <br /> Other i Rotary Type of Grout <br /> Other Other Information <br /> PUMP'-INSTALLATION. Contractor <br /> — --Type of&-Pump.-- — r - - .� H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP REPAIR: State Work Done Gly <br /> ESTRUCTIOW OF WELL. Well Diameter j - - <br /> 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 f <br /> and the State -of California pe.rtaining,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 ` k <br /> _ � � TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I } <br /> APPLICATION ACCEPTED BY Iz 16z6�7� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY N/ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND .FINAL INSPECTION: , .^ <br /> E H 1426. 7/72 1M <br />