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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 E <br /> P ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED 'Date .Issued <br /> (Complete In Triplicate) <br /> Application isereby 'made to the San Joaquin Local Health District for a petmit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1562 and the Rules and Regulations of the San .Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION aQ CENSUS TRC <br /> Owner's Name 119L �.�. �� Phone <br /> Address O C7 �G1�}..3 �. �LG� ` �� City <br /> Contractor's Name �L � „J _ �� License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR Y PUMP REPLACEMENT /_7 <br /> Other J J -" <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE., TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> Other Rotary Type of Grout <br /> Other Other Information n ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> P H.P. <br /> PUMP REPLACEMENT: / / State Work Done p� <br /> PUMP REPAIR: / / State Work Done. 19'/2,9 <br /> .t <br /> ESTRUCTION OF WELL: Well DiameterApproximate 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 /> SIGNEDTITLE � � _ <br /> (DRAW PLOT LAN ON REVERSE SIDE) V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E DATE {jj -� -- �2 nj <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE MtFJVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING-AND FINAL INSPECT � <br /> E H 1426 <br /> 7/72 1M <br />