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SAN JO, QUIN LOCAL HEALTH DISTRICT <br /> FOR 0 ICE USE: 1601«E. Hazelton Ave. , Stockton, Calif. ! <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 6 <br /> THIS PERMIT EXPIRES 1 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 o. 1862 and, he <br /> Ry, e an Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRE5 CATION `� / X0'1 9e <br /> CENSUS TRACT <br /> Owner's ame Phone <br /> Address 6 Q City <br /> Contractor r s Name_ License # IZ02Z.V Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /_� DESTRUCTION. /_7_ - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMPREPLACEMENT /_7 <br /> Other /_7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK p SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED [ISE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled ' <br /> Dia. of Well Casing 14 71 <br /> Domestic/public i Driven Gauge of Casing1� R . <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Other # Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATIONC Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> } <br /> PUMP REPAIR: "� � -' / State Work Done + <br /> ESTRUCTION OF WELL: Well Diameter <br />�—__- . __.., -, � � Approximate Depth ��- <br /> E ` Describe Material and Procedure <br /> I hereby agree to comply withiall 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 onla 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 t TITLE <br /> ? (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE, Oelll?3 <br /> ADDITIONAL COMMENTS: <br /> AGRO <br /> II GROUT I SPECTI N P E III +INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 77 <br /> CALL FOR AINSPECTION PRI R TO GROUTING AND FINAL INSPECTYON. <br /> E H 1426 7/72 1M <br />