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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> __--d 1 7,--17? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 CENSUS TRACT <br /> Owner's Name Phone �/ j Ku <br /> Vr O � <br /> Address City Z / <br /> Q �'] <br /> Contractor's NameWY,1J, AlLicense # Phoneb�X373 <br /> TYPE OF WORK (Check) . NEW WELL lPr' DEEPEN /% RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br />} DISTANCE TO NEAREST: SEPTIC TANK �c5_' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s <br />'E INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />'r Industrial =Cable Tool Dia. of Well Excavation (� <br /> =omestic/private Drilled Dia, of Well Casing p <br /> s. Domestic/public Driven Gauge of Casing <br /> /Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br />(E Other Other Information <br /> r <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump H.P. 77Z <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE Z-1 i?/ 92 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY [a d `7, . DATE - INSPECTION BY DATE <br /> F <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />