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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'.Av'e. , Stockton, Calif. <br /> � 'Telephone:' (209)466-6781 <br /> APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. ,Z?_2 41 �) <br /> {Complete I YEAR FROM DATE ISSUED 7 1J3 <br /> THIS PERMIT EXPIRES 1 FSED Datie- Issued 6- <br /> .._ -_ ,--�— <br /> In Triplicate) <br /> Application is hereby made to the San Joaquiii 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 Z/ t5 /�- CENSUS TRACT <br /> Owner's Name J p = • Phone <br /> Address . - City <br /> i <br /> Contractor's Name _ � �� N�'� :5 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /Oe"'DEEPEN / / RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /X/ <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 I Cable Tool.; Dia, of Well Excavation , <br /> =Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public F Driven Gauge of Casing - 2 y. <br /> Irrigation1 ravel Pack Depth of Grout Seal <br /> Other L �Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump H.P. A <br /> PUMP REPLACEMENT: / / State Work Done <br /> r..PUMP REPAIR: / / State Work Done <br /> V <br />�;PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> — <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 ue to the 'be t of my knowledge and belief. <br /> SIGNED TITLE <br /> ;1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR:.DEPARTMENT USE ONLY <br /> PHASE I 1 j <br />_APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i - ` <br /> PHASE II GROUT INSPECTION ! PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT - 9-?3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. F <br /> E H 1426 7/72 1M G� <br /> 4 <br />