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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 31:6 Q <br /> THIS PERMIT EXPIRES l 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 /> .TOB ADDRESS/LOCATION 2 4 9- 6 CENSUS TRACT n <br /> Owner's Name Phone' <br /> Address <br /> city <br /> Contractor's Name _ n� r 4L n ,,/ License Phone '8 3R] o <br /> TYPE OF WORK (Check). NEW WELL /-7 DEEPEN /J RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /-1 <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 <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 /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done f?t T <br /> PUMP REPAIR: / / State Work Done �T <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> 1-hereby agree to comply with all laws and regulationskof 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 of my knowledge and belief. <br /> SIGNED f TITLEA 4, ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> / � g <br /> APPLICATION ACCEPTED BY �� DATE Com/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PMSIr I NAL INSPECTION <br /> INSPECTION BY DATE INSPE DATE -3 - :j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />