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SAN JOAQUIN LOCAL HEALTH. DISTRICT 407'y S�c�1c r-rte 6-VI <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. # <br /> Telephone. ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 14o.,3_JD 7/,,0 <br /> THIS PERMIT EXPIRES l .YEAR FROM DATE ISSUED Date Issued 11 <br /> (Complete In Triplicate) <br /> a <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..i1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION f- I �-- �J�`r �. CENSUS TRACT <br /> Owner's Name A� fes- R Aly Cl - ex o ,,/ � Phone <br /> Address 3 2 City <br /> ,e �� <br /> Contractor's Name . . ,. "'Licrense # Phone <br /> TYPE OF WORK (Check) : NEW WELL/;/ ' DEEPEN/ / RECONDITION /,/ DESTRUCTION /7 f <br /> PUMP INSTALLATION /ff.—PUMP REPAIR '/—/ PUMP REPLACEMENT /7- i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Lf,, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domdg.tic/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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> . I <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP REPAIR: /_7 State Work Done <br />} ,DESTRUCTION OF WELL:_ _ W_e11-Di'ameter - _._..Approximate Depth <br /> Descrie 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 bes of my knowledge and belief. <br /> SIGNED TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDt) K..... <br /> F R DEPARTMENT USE ONLY <br /> PRASE T <br /> APPLICATION ACCEP D BY DATE <br /> 0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I AL INSPECTION <br /> INSPECTION BY DATE INSPECT DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />