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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (203) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..J'l --3/ <br /> x <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 - u., [ S-"'CENSUS TRACT 0( Q-Z70-03 <br /> Owner's Name _, � Phone <br /> Address 4r City f <br /> • <br /> Contractor's Name =`} /,,; ;,_i C T jl-6 License #112770/Phone.' <br /> TYPE OF WORK (Check) : NEW WELL % DEEPEN ,/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / 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 SPECIFICAXIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well. Casing <br /> -y� <br /> Domestic/public Driven Gauge of CasingM- <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout f' z <br /> Other Other Information �rt <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _./ / ` State Work Done <br /> PUMP REPAIR: / / 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 s' true to :the beamyIknowledge and belief. <br /> SIGNED e�• ~. ��-..�� TITLE <br /> 71 <br /> (DOW OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PkTASE // . _/_ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY, DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT .ON. <br /> E H 1426 4/72 1M <br />