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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ tjs vel <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued _!�-L=� <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 /> i Count . Ordinance.No,• 1862 and the -Rules and Regulations of the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT Loi- b 0.3 <br /> Owner's Name CD Phone �1D ,5,2 - M <br /> CI <br /> Address City ��.��,.__d <br /> Contractor's Name License # Fhone t3 -- <br /> TYPELLOF WORK (Check) : NEW WELL /1� DEEPEN /? RECONDITION / DESTRUCTION / 7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT 17 N <br /> Other / / 4112 a19 a4A -to <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 SPEC ^' CATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ZW <br /> Domestic/private Drilled Dia. of Well Casing t4 if _ <br /> Domestic/public Driven Gauge of Casing WAtj <br /> -- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractors " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> DUMP- REPAIR.- `�-� /_=t State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �r Describe Material and Procedure <br /> I hereby agree comply a to with all laws and regulations of the San Joaquin Local Health District <br /> P Y <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 4 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �} ) <br /> ! APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY 3 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />