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r <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.- Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. 1.Z-/»lrl <br /> THIS PERMIT. EXPIRES 1 YEAR FROM` DATE ISSUED Date jssued <br /> (Complete In Triplicate) <br /> Application is hereby 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 compliatice 'w 'th San Joaquin <br /> County Ordinance No. 1862 and the Rules and Re u_lations of the Sart Joaquin Local Health listrict. <br /> WP <br /> JOB ADDRESS/LOCATION-1- p, a ' <br /> Vim` `, CE%US TRACT <br /> Owner's Name ,.,` ��; Phone Ds� <br /> Address �� City p <br /> Lo - .._.. —-:-•- ....—... 91-94 <br /> 31�w <br /> Contractor's Name License # l Phone �� 73��0 <br /> TYPE OF-WORK• (Check) : NEW-WELL*I&F- DEEPEN /-7 RECONDITION- /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> L. � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/privateDrilled Dia, of Well Casing u �f ��,. A dj 4 <br /> k <br /> Domestic/public .: Driven Gauge of Casing Jd .�'lcc� _ ___• ,q <br /> - _ Irrigation Gravel Pack. Depth of Grout„ Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 5 <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION-OF-WELL•— e-11-Diameter 'APProximat`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 nvt.ify 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 /> a 11 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />-PHASE I <br /> APPLICATION .ACCEPTED BY DATE %� <br /> ADDITIONAL COMMENTS: ' C <br /> PHASE II ,GROUT INSPECTION <br /> PHASE -/,,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> L <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />