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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR '+O VICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, t <br /> Telephoner (209) 466-6781 <br /> APPLICiiATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit- No <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ol� -? 3 <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _y CENSUS TRACT `S 7 <br /> Owner's Name �= <br /> ° Phone 3 -- - <br /> Address ll City C&der-fs <br /> Contractor's Name License # IAJJ,�o Phone .2aErk <br /> TYPE OF WORK ( NEW WELL DEEPECheck} ; / / N_/ ./ RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION-,/ / PUMP REPAIR X PUMP 'REPLACEMETiT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD C POOL/SEEPAG PIT OTHER <br /> INTENDED USE TYPE OF WELLti CONSTRUCTION, SPECIFICATIONS <br /> - industrial Cable Tool % Dia, of Well Excavation <br /> Domestic/private Drilled "/-Dia. of Well Casing <br /> Domestic/public 3 Driven Gauge of Casing , <br /> -- Irrigation i Gravel Pack Depth of Grout Seal` <br /> -- Other <br /> - Rotary Type of Grout , , <br /> ! Other Other. Information, <br /> f S <br /> PUMP INSTALLATION: "Contractor <br /> Type of Pump �• <br /> H.P. ?D <br /> PUMP REPLACEMENT: %/ State Work Done ' <br /> PUMP REPAIR; ' State Work Dane <br /> � . <br /> i <br />,DESTRUCTION OF WELL: Well Diameter <br /> - --- 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 true to the est of my knowledge and belief. <br /> SIGNED o TITLE Xly <br /> RAW PLOT <br /> PHASE I ARPLAN ON REVERSE SIDE): <br /> FOR DEPTMENT USE ONLY <br /> e <br /> APPLICATION ACCEPTED BY DATE ef` O �7 <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> 6A,LL FOR A GROUT INSPECTION.PRIOR TO GRdttING AND FINAL INSPCTIO . + <br /> E H 1426 CCL,,� fi--c-04 7i 7/72 1M-1 <br />