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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> ` FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. E%9Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Appl cation 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 /> 4& <br /> County Ordinance No. 1862 an s an o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �6 c7"/� CENSUS TRACT <br /> i <br /> Owner's Name 4P Phone <br /> `` 1►-���. <br /> Address C a/�� -rr City <br /> -.- <br /> COntractor's Nam ,� •/� . {��+® � �,c��CC _ �/1 Lim License �� Phone <br /> h-r3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT- <br /> Other <br /> EPLACEMENTOther <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ass , OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation - 1 <br /> Domestic/private a Drilled Dia. of Well Casing <br /> i .. Domestic/public Driven Gauge of Casing a <br /> k Irrigation Gravel Pack Depth of Grout Seal SjO __- <br /> Other Rotary Type of Grout <br /> 1 Other Other Information - <br /> r - <br /> PUMP INSTALLATION: Contractor A 11,411,0 �e <br /> Type of rump 4eu -- .0 - 7, <br /> r H.P. <br /> PUMP REPLACEMENT: / / <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done _ <br /> , J)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 /> and the State of California pertaining, to or'r;6�gislatingwell construction. -Within-FI-FTEEN 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 trueto he best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ! APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE a27 INSPECTION BY DATE / <br /> t CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />