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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone:. <br /> (209) .466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR 'PUMP PERMIT Permit No <br /> cf `( <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 57,C-I-V <br /> (Complete In Triplicate) <br /> Application,is,her:eby 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 /> JOB ADDRESS/LOCATION Xra r. r8 ate- _ _ CENSUS TRACT' <br /> Owner's Name x.� fj 5,t cz ;i Phone <br /> 4 Address R -29 CityZ4 e <br /> Contractor's Name - License # .Phone ' <br /> _-�TYP_ OF WORK (Check) : E WELL DEEPEN /7 RECONDITION / . DESTRUCTION �T <br /> PUMP INSTALLATION-/ / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <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 6e <br /> Other — Rotary Type of Grout <br /> Other Other Information ' O <br /> j PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR: / / State Work Done <br /> �_ ,�,".�..: rt• le��.rr._.' .c x .�:.♦sF mow.. •---�.,t�-. .�-���::' i+:crr^�.'^vww. _ ' <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 of my'knowledge and belief. w <br /> SIGNED TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIAL,,INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6.- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426`' <br />