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/A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICE USE: �/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209) 466-6783 <br /> s APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ��-39-0- <br /> THIS <br /> 3a.°-THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 3 <br /> (Complete In Triplicate) <br /> Application is .hereby made to the San Joaquin Local Health District for a -permit to construct F <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> County Ordinance No. 1862 and the l��s d Regulatior}s of the San Joaquin Local Health District. r <br /> l�f .�"�r�l� e, e, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name r"z7 Phone <br /> Address <br /> City <br /> ' �' . <br /> Contractor's Name License 4f�� PhoneAA <br /> TYPE OF WORK (Check) :,—NEW WELL /7/ DEEPEN / / RECONDITION <br /> AL /_� DESTRUCTION /_7 PUMP INSTLATION / / PUMP REPAIR /)Cf PUMP•.REPLACEMENT -1-7 - <br /> Other <br /> /-7 -Other 17 <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 <br /> Industrial Cable Tool Dia. of Well Excavation _ �Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> •Domestic/public°' Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -W_ Other Rotary Type of Grout / <br /> Other Other Information <br /> 4 f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump --Mt. f./ R.P. <br /> PUMP REPLACEMENT: /!, / State Work Done <br /> 4 PUMP REPAIR. /n/ State Work Dane <br /> ' ._. U r <br /> ? ESTR7CTION.OF_WELL:- Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <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 m owledge a---b lief. <br /> SIGNED / � � LE <br /> F ( WLO PLAX­ ON' REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> GC/!lit <br /> 1 APPLICATION ACCEPTED BY �_ 9/'�• �- �.�+,— --- L.2 /5 —� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />