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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. Z-iv-o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued fT/ <br /> (Complete In Triplicate) �— <br /> Application is hereb 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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> r: <br /> Owner's Name Phone 14 to �- <br /> Address � �f , � �. ---- - -- City <br /> Contractor's Name � .,, 41!9,t. -ra�y� License #AX323 Phone 31; � <br /> s <br /> TYPE OF WORK (Check) . NEW WELL/ / DEEPEN -/_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR jg� PUMP REPLACEMENT /-7 <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 <br /> Industrial Cable Tool - Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 Z., H.P. j <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _ f " 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 b st of my knowledge and belief. <br /> SIGNED -�-�'f TITLE <br /> JtL (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q r� <br /> APPLICATION ACCEPTED BY -- - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II '/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> 1 <br />