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SAN JOAQUIN LOCA- REALTH DISTRICT <br /> OR OFFICE USE: V 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ;�;!J— /zo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued <br /> 1 (Complete In Triplicate) <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 �d .the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name 'L� s ,`y�'_ �e-t (_ - Phone `' �Cla_ <br /> Address <br /> ���--- •�- /mac-4J�i.. _ - - - ----- -- City <br /> Contractor's Name LicensePhone6��� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN 't,;< RECONDITION /- DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR fSQ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD Z2,:?-: 'CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE 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 Z-2 <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Other 4. Rotary Type of Grout _ - el <br /> Other Other Information C !I <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <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 tr o the be of m nowledge and belief. <br /> SIGNED TIT <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ir <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE IIG UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY DATE 3-� 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br />