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SAN JOAQ-AN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ S4 k) <br /> A THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zr,25'----�b. <br /> , 422 ,4,�� . ( (Complete In Triplicate) S_1-5-0.-/ 2 <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 and the Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Mai CENSUS TRACT <br /> Owner's Name Phone ;939'- J34� <br /> Address 1 ,(� r City. _4U"Z 2 <br /> Contractor's Name License # 2V Phoned_ y� <br /> TYPE-OF WORK (Check) : NEW WELL �� DEEPEN- /-7 RECONDITION /_� DESTRUCTION-// <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <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 /> T- <br /> PUMP <br /> INSTALLATION: Contractor 9 m <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> ff 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 /> r SIGNED TITLE _ <br /> D PL PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE '- 3V <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR IN E T PHAg III FINAL INSPECTION <br /> INSPECTION 'BY TE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1 E H 1426 �,�(�,,,: ��.-,-C-�QG 7/72 IM <br />