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SAN JOAQUIN LOCAL HEALTH DISTRICT 'r?� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Et Telephone i (209) 466--6781 <br /> _ <br /> TAPP IGION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z (o <br /> _ q <br /> ,ATS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued 7_ 1Z--7-t�l <br /> ��, (Complete In Triplicate) <br /> Application is hereby ma.d�rto the San Joaquin Local' Heal.th District for a permit to construct <br /> and/or install the. work Grein 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 I. ! 3 C� CENSUS TRACT <br /> Owner's NamePhone ' 7, <br /> Address ! , .< City _ rr1 <br /> Contractor's Name f�_z� / ,j ,��„ ( ,;t F)� License # Fhone <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN '/ / RECONDITION / / DESTRUCTION /-T f <br /> PUMP INSTALLATION REPAIR '/K / ` PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 L , <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 /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done e- <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree to complywith 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 knowledge and belief. <br /> SIGNED _J�j, ,4- )92 TITLE <br /> {DRAW PLOT PL11rA1 ONR VERSE SIDE) ^ <br /> FOX DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY �J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' Ti <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />