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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: „j� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 -96-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .49--7a-7j- <br /> (Complete <br /> -,3a-7L <br /> (Compl,ete 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 f &LALIMA41-2 Lila. 21L <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address g 5A, City , <br /> Contractor's Name A License #C. 7 Phone R�f7-f739y <br /> TYPE OF WORK (Check) : NEW WELL Ll/ DEEPEN /-7 RECONDITION ./-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES pr,'4- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD g5`+ CESSPOOL/SEEPAGE PIT OTHER` <br /> C <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation- <br /> Domestic/private <br /> xcavation Domestic/private Drilled Dia. of Well Casing $► <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,r- ,O. <br /> Other 2!� Rotary Type of Grout <br /> Other Other Information ••—•__.._�� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ! H.P. aZ - <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 /> informatio true. to th be o y knowledge and belief. <br /> s . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY- . <br /> • PHASE I t <br /> ,LAPPLICATION ACCEPTED BY, DATE <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE =7.-�y INSPECTION BY DATE -:3 �Zr <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />