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f <br /> SAN JOAQUIN LA'�A-L EALTH 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 2 <br /> f r (Complete In Triplicate) V2o --30 <br /> Application is hereby made to'Ithe 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 /> j.cF Z 2 .S _ uc-7b , <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamePhone YQy'-.4102t;44 044L j <br /> Address R f .7 �i. rt - - - - -- City <br /> Contractor's Name License # Ja7o�z y Phone <br /> . t7 , <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 WELL CONSTRUCTION SPECIFICATIONS to ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 10S <br /> Domestic/public Driven Gauge of Casing fa A&f_ <br /> ri <br /> - Irrigation I 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: / / St ate Work Done <br /> PUMP REPAIR: / J State Work Done <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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I j. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II 4ROUT INSPECTION PHASE III1FjXL INSPECTION <br /> INSPECTION BY &4eAe DATE INSPECTION BY DATE /a -~23_ <br /> CALL F'OR.A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M `�kJ <br />