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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFx:CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> y- /6 71p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 JCC <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS f9ftTleNza) CENSUS TRACT <br /> Owner's Name 1— /Z L Phone <br /> Address _ c y p city <br /> Contractor's Name r 5 License Phone <br /> TYPE OF WORK (Check) : NEW WELL&%. .DEEPEN /_%. RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /F PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /- 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES = 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 MQ <br /> Domestic/private Drilled Dia. of Well Casing _ _ 0 <br /> Domestic/public Driven Gauge of Casing / Z <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Other Rotary Type of Grout 7 <br /> Other Other Information <br /> PUMP INSTALLATIONS Contractork4h-rtnea s .� <br /> Type of Pump ` H.P. 5 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 /> 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 /> SIGNED2f ? _ TITLE .GG�`� <br /> ����ALOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE I-II/FINAL INSPECTION <br /> INSPECTION BY DATE -►3„Z.`-f INSPECTION BY _ DATE <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INS TION. <br /> E H 1426 7/72 1M <br />