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-t V SIGN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' <br /> +4-�'L <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 Joaq p Local Health District. <br /> JOB ADDRESS/LOCATION r_ <br /> �G s-� r r ��7A�.o CENSUS TRACT <br /> Owner's Name Phone <br /> Address (0 a 3d� 0]p4 C�� <br /> �y City G <br /> Contractor's Name 450k 4 License #/13 73-C Phone. W,2-74/74 <br /> TYPE OF 'WORK (Check) : NEW WELL /7 DEEPEN /�/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / J PUMP REPAIR g/ PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY n <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 75 <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 0 W p y � 1 <br /> ESTRUCTION 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 knowled and belief. <br /> SIGNED I TLE <br /> (OW PLO PLAN ON RE SE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY., DATE f j� <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GRO N PWOWO INSPECTION <br /> INSPECTION BY. A E INSPECTION B DATE _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I N <br /> E H 1426 7/72 1M <br />