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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 37 <br /> Zf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 <br /> / I v st / cr-n oR <br /> -- � ,.�Q..�— � y 1,171 /P_� C NSUS TRACT <br /> Owner's Name a C7 1A PhoneS"I <br /> Address <br /> City <br /> Contractor's Name e) L° h. License # Phone <br /> P <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /__/ RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <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 <br /> Industrial Cable Tool Dia, of Well Excavation � b <br /> Domestic/private Drilled Dia. of Well Casing 4 <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 p <br /> Type of Pump H.P. 5 {{ <br /> PUMP REPLACEMENT: / / State ork Done I <br /> PUMP REPAIR: 5tad Work <br /> on <br /> / Work <br />.PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 j <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 TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: .2 7.,� dy, <br /> PHASE II GR6Ut,7IWSPBZT1r0V EaSEqITZFIKAL INECTIUN <br /> INSPECTION BY DATE E INSPECTION BY 147. - DATE 2 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTkNG AND FINAL INSPECTION. <br /> E H 1426 7/72 IM AJ <br />