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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [FOIR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,U /V_5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , 6� -,-3 <br /> (Complete In Triplicate) <br /> 6 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 /> CountyOrdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .. —r?o.--/a <br /> JOB ADDRESS/LOCATIONI=A19 AMdCENSUS TRACT <br /> Owner's Name Phone faR�— Lb3 <br /> Address '�s _ am f _ City <br /> i <br /> Contractor's Name License # /.2�`!� Phone gam. •7S'76 <br /> i TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /� <br /> �/ r <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 3 Other / / plc ra 4 „ , 19A �rr,9tac•L <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 I4tA _ <br /> 'E 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 /> } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 4 �^ y <br /> ,DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> 'Describe Material and Procedure <br /> 4 � - <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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 13 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS T4JFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> r <br />