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A t <br /> SAN JOAQUIN LOCAL FEALTH DISTRICT <br /> FOR OFFICE USE: v 1601_ E. Hazelton`. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> k PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />+IVe _ <br /> 4 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- No. 1862, an'd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> f Owner's Name Phone &/- 3,3 Y2 <br /> a <br /> � <br /> Address _ 0 . � - � �- - - _ City �r <br />! Contractor's Name License # //�j7j Phone��,/•Y�- sJ <br /> TYPE OF WORK '(Check) : NEW WELL/ / DEEPEN / RECONDITION /`/ DESTRUCTION /_7 v <br /> PUMP INSTALLATION/ / PUY.P REPAIR / PUMP REPLACEMENT /7 <br /> i <br /> r Other / / � • <br /> f� <br /> DISTANCE TO NEAREST: SEPTICITANK 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 <br /> Domestic/public Driven Gauge of Casing r V <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Donis* � y <br /> PUMP REPAIR: J / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate 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 /> i 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 !r�e In• � n i�`h!^i TITLE ` � 11v1 en.I� YYl h.,�r a r✓.- <br /> __ (DRAW PLOT /-PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY 7, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M I ' <br />