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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FbR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. $ <br /> j. Telephone : (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.':_ Sia <br /> Tom_ 7o G4/o <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) n -5.53-0 ? <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> 3� AiIA,-te I"NSUS TRACT <br /> Owner's Name ` 1'h y � L Phone <br /> Address City <br /> Contractor's Name f� License 7dfd Phone <br /> TYPE OF WORK (Check) : NEW WELL )k7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / r PUMP REPAIR / / PUMP REPLACEMENT /? �. <br /> .. Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK tSEWER LINES �_ PIT PRIVY�-- <br /> SEWAGE DISPOSAL FIELD G*RftOM/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 16 <br /> Domestic/public Driven Gauge of Casing -- -f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> Z'. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> . _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: . 17�'d e,ir=.-es� <br /> PHASE Il GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE _ 1z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H1426 7/72 , 1M <br />