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6� 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.,3-68 `� <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 /> CountylOrdinance_No 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/IX CATION /,(J, % 3 C� ICe, �CENSUS TRACT p�g- !so <br /> i Phone36, /^Cv y K� <br /> Owner's Name <br /> Address City <br /> Contractor's Name _L'CLicense iE/ 23:23 Phone36 - 3� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR f.5;? PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 -7- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: /—/ State Work Done <br /> PUMP REPAIR: /TY�'- State Work Done -- + _ ��.au ,,� <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 best o 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 /`d2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /A -1-d <br /> CALL:,F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION: .. <br /> E H 1426 7/72 1M <br />