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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> �. Telephone: (209) 466-6781 <br /> leLlCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q 7 O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � �i L- 7 L <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 ofp they Soman Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /241V/ CENSUS TRACT ' 5 W <br /> Owner's Name Phone,,-/ 0_ _ <br /> Address City �i r <br /> Contractor's Name _ License 0`G137?7? Phone3jkj <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR _J-V PUMP REPLACEMENT /-7 <br /> Other I / <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 t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r` <br /> Irrigation Gravel- Pack Depth of Grout Seal <br /> Other Rotary Type of Grout g'' <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor 4.. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> .DESTRUCTION 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 rue to the best of my knowledge and belief. <br /> SIGNED TITLE _ - - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE P- 2:Z12 --72to/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '- -/,g-- <br /> CALL <br /> yCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 6) P-A, <br /> E H 1426 4/72 1M <br />