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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: z,� 1601 E. Hazelton Ave.-, Stockton, Calif. ' <br /> Telephone * (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE;' ISSUED Daae Issued .//--z-- <br /> (Complete In Triplicate) �J: <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.M and tie Rules nd. Re u1 ons of the' San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION : �' CENSUS TRACT <br /> Owner's Name - �� ' Phone U cP �5Z <br /> Address c � f, € City ??�- �.� <br /> � � <br /> Contractor's Name Lense # A'6c7 6 Phone <br /> y <br /> 0,-167,6 <br /> j�. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /J7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / J PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> kN � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation `1�} <br /> Domestic/private = Drilled Dia. of WeA Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout + <br /> 1 Other Other Information <br /> �I <br /> PUMP INSTALLATION: Contractor „rte <br /> Type of Pump " H.P. <br /> E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> J)ESTRUCTION OF WELL: Well Diameter I 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 LOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I " € <br /> APPLICATION ACCEPTED BY ® DATE <br /> ADDITIONAL COMMENTS �. <br /> PHASE II GROUT INSPECTION PHASE AII FINAL .INSPECTION <br /> INSPECTION. BY DATE INSPECTION BY DATE -? <br /> �I _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.. <br /> E H 1426 ' 7/72 1M <br />