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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 112 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1z--2k-72(Complete In Triplicate) bS'/� bra-z7 <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,.th.e.Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT i <br /> .Owner's Name i Uj ° vB Phon <br /> .! - <br /> Address a.� �p0,ee • tt°e4 w city <br /> vcv� i <br /> Contractor's Name ' "�� ' <br /> License # 1x.( ' p Phone <br /> TYPE OF WORK (Check)'-.- NEW WELL '/—/ DEEPEN /_/ RECONDITION /-7 DESTRUCTION /? y <br /> PUMP INSTALLATION /� .PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other / / —'\1 <br /> DISTANCEyTO NEAREST• EPTI TARK SEWS LINES PIT PRIVZ <br /> SEWAGE DISPOSAL.FIELD . 'CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS6 , <br /> Industrial Cable Tool Dia. of Well Excavation <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 t <br /> PUMP�REPAIR" `T ' ` "` - <br /> '�/�/- "State Work=Donees - <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 true to the st of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> J(� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��-�-�Z- <br /> ADDITIONAL COMMENTS: <br /> PHASE,, II GROUT INSP&CTION PRASE IIIIFINAL INSPECTION <br /> INSPECTION BXDv_ INSPECTION BY ,/ ,y DATE f/ - <br /> CALL FOR A GROUT INSPEC�'ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br /> f <br /> s <br />