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{ " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued (y� 7; <br /> 4 <br /> (Complete In Triplicate) 9 Q Q <br /> Application is hereby made toithe San, Joaquin Local Health District for a permit to construct <br /> and/or install the work herO,_n described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and Rules and Regulations of the San Joaquin Local Health District. s <br /> JOB ADDRESS/LOCATION cP � o`�-•� �-u� / _ CENSUS TRACT S y <br /> F GP <br /> J Phone 4 - Ze d-:L 4' <br /> Owner's Name <br /> Address fes/ �rr0 q� City <br /> Contractor's NamesS 6 ,/ License #//Slcl� Phone-1Z d- 414 <br /> TYPE OF WORK (Check) ; NEW WELL"Z/ DEEPEN '! I RECONDITION I� DESTRUCTION "/-T <br /> PUMP INSTALLATION/ / PUMP REPAIR! / PUMP REPLACEMENT <br /> Other '/ <br /> r <br /> DISTANCE TO NEAREST: SEPTIC {TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial I Cable Tool Dia. of Well Excavation �d <br /> j }( Domestic/private '.iT Drilled Dia. of Well Casing <br /> Domestic/public a Driven Gauge of Casing <br /> Irrigation A Gravel Pack Depth of Grout!:�� <br /> Other 1 Rotary Type of Grout ' <br /> i Other Other Information` <br /> 1 � <br /> PUMP INSTALLATION: Contractor , �� H.P. 2 <br /> Type;of Pump � 1� <br /> PUMP REPLACEMENT: / / ;State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well. Diameter <br /> Approximate Depth Q <br /> Describe Material and Procedure <br /> 00.1 <br /> 1 with all aws and egu tions of the San Joaquin Local Health District <br /> I hereby agree to comply y <br /> and the State of California pertaining to or regulating well construction. Within FTFTEEN :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 th best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> rPHASE I • . >f ,. � -- - • -: . . . <br /> j APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT; INSPECTION PHAS <br /> INSPECTION BY i DATE -Z7-7 2-- INSPECTION BY DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' <br /> 4/72 1M <br /> E H 1426 <br />