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v� 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 <br /> THIS= PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 9_-a.2 7S . <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/LOCATYON $ # , c /If. �9 !�/� CENSUS TRACT <br /> Owner's Name Phone <br /> Address S ✓in City C! <br /> Contractor's Name License ./f f /Phone-_::)'C- <br /> TYPE <br /> Phone�'C <br /> e <br />_ TYPE OF WORK (Check): NEW WELL _7 T DEEPEN /� RECONDITION /� DESTRUCTION %]` <br /> PUMP INSTALLATION Zj/ PUMP REPAIR / 7 Pump REPLACEMENT 17 <br /> Other 177 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation,- Q ; <br /> Domestic/private t Drilled Dia. of Well Casing (�R ; <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type -6f-Pump r v ,St�f�f�i Q.fsr`7�'7 --- H:P <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> 4 <br /> PUMP REPAIR: / / State Work Done - N kk <br /> V <br /> f" roximate <br /> ,DESTRUCTION OF WELL.: Well Diameter App Depth <br /> Describe Material and..•Procedure <br /> I hereby agree tocomply with all laws and regulations of the .San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating 'wiell 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 rue to the best of my knowledge and belief. <br /> SIGNED TITLE '. -1- - <br /> sDJFW.PLOT PLAN ON REVERSE SIDET <br /> Y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 0�47___ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 77 <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL-INSPECTION. <br /> E H 1426 7/72 1M , <br />