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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No. 7_- /a3kl <br /> tff <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued �.Z. <br /> .La-.3l- <br /> (Complete In Triplicate) fid_ <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' he Rules and Regulations of the San Joaquin Local Health District, i <br /> ,j v* r� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name /L % Phone <br /> Address City <br /> f <br /> Contractor's Name �y' _ j License # j Phone <br /> LIC; 3�,.�+5 - <br /> TYPE OF WORK (Check) : NEW WELL}' DEEPEN '/ / RECONDITION /_ DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /?' <br /> 0 Cher / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER " <br /> R ry <br /> INTENDED USE TYPE OF WELL <br /> -CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation _fes _ <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven v Gauge of Casing 4 <br /> --6� Irrigation Gravel Pack Depth of Grout Seal , <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> PUMP INSTALLATION:- Contractor <br /> T <br /> - <br /> Type of Pump" %i� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure Mf 1 <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.4" <br /> SIGNED TITLE Ce-1,17,el TOA <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE7 - <br /> ADDITIONAL COMMENTS; - <br /> -- <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY tAdLte DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �� 4/72 1M <br />