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Q SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued 2 <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 Lb CENSUS TRACT <br /> Owner's Name 2Phone <br /> Address 6R0 S f�u,G r., City <br /> Contractor's Name �YL f YRS (, ,� � License # 1L2373 Phone 44 W U_,_ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ -PUMP REPAIR / / PUMP REPLACEMENT <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavation kA <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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR, j / State Work Done <br /> ESQ TRUCTION 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 sl t ,1 )r, s�1LL� TITLE f1 <br /> (DRAN PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Q q� <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �(�� -_ _- DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />