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rSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stockton Calif_ . <br /> -. Telephone : (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU;"iP PERMIT Permit No. <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 applicatioxi'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 ,U CENSUS TRACT <br /> Owner's Name ' . PO 00� SSC R <br /> Phone $ - t <br /> Address <br /> City <br /> i <br /> Contractor's Name _ -T=[]" - .Z/ _ License 4� ' ]�jO1� Phone ? j <br /> N <br /> TYPE OF WORK. (Check) : NEW WELL /_7 DEEPEN /7„ RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /Z► PUMP REPAIR / / PUMP REPLACEMENT /_7 lNr+ <br /> Other / / --- M <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD wr CESSPOOL/SEEPAGE PIT <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 <br /> Other Rotary Type of Grout <br /> Other Other Information ° <br /> rlvv .# y �►► 7e.�G 6,G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -� mzz�.-"dJ. H.P. �[7 <br /> s <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR:r <br /> '�"'�'�_. ./_/ . -S-tate- Work Done <br />,DESTRUCTION OF WELL: Well DiameterApproximate 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 fu 'niish ?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 tothe est of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> : (DRAW PLOT PLAN ON`REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY DATE 1r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BYi,�._ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM, <br />