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SAN JOAQUIN LOCAL HEALTH DISTRICT \/ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.", Stockton, Calif. h <br /> Telephone: (209) 466-6781 \ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -027,//o g <br /> THIS PERMIT EXPIRES'] YEAR FROM DATE ISSUED Date Issued <br /> II (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"-N6. 1862 an& the' Rules and-Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIOI3 ' I. CENSUS TRACT <br /> t . � � Frit:: - 3(=2r - 0/99"7' <br /> Owner s�Name Phone3(=2r- 0/99"7 <br /> ff <br /> Address � ,of '=�. '` 4 - City <br /> Contractor's Name License #Is 3z- Phone J• 7' <br /> � I <br /> TYPE OF WORK (Check) : NEW WELL / :/ DEEPEN /- RECONDITION /-7 DESTRUCTION /^7 <br /> PUMP INSTALLATION / rrPUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ISEWER LINES PIT PRIVY <br /> SEWAGE .DISP(5SAL FIELDI CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONSJ I <br /> - <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 /> 4 Other Rotary Type of Grot <br /> Other° Other Information , <br /> e101K2�mln��11I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump's H.P. <br /> PUMP REPLACEMENT: / / State Work Done. <br /> x _ <br /> PUMP-REPAIR o"`6--r-��7ZP-`=•Sta•teYWork- Done.- -` <br /> J)ESTRUCTION OF WELL: Well Diameter > ,` Approximate Dept <br /> Describe Material{and,-Procedure ...-a' <br /> 1 j <br /> I hereby-agree,.to.comply�with all laws and regulations of the San Joaquin Local health District <br /> and the/State of Californiaa pertai-n`iiig to vt�reguli ting'wel7l:c6nstruct°ion.--,..With_in FIFTEEN DAYS <br /> after completion of my work on a new well, I will rfurnish the San Joaquin Local Health- District a <br /> WELL DRILLERS REPORT of the well and notify`;them�b'eforeputting\the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED/' z� - =- �- - -=; ,._•. TITLE .. . <br />`r (DRAW PLOTr•PLAN ON"REVERSE SID <br /> FOR DEPARTMEN'IV,$g'"ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> E ADDITIONAL COMMENTS: s ? <br /> PHASE II GROUT INSPECTION t PHASE III,/FINAL INSPEC 1013 <br /> INSPECTION BY DATE � � INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H :1426 # 7/72 1M <br />