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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave;, Stockton, Calif. � <br /> Telephone : - (209) 466-6781 F <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 Z ?) Z <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7 <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/LOCATION <br /> 4 ' A CENSUS TRACT . <br /> Owner's 'Name it, Phone i <br /> i <br /> Address kFk <br /> ' City 1 <br /> ,`t n <br /> AF <br /> Contractor's Name �` License �`"�' <br /> hone . <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /%/ RECONDITION /� 7 'DESTRUCTION /_7 <br /> PUMP INSTELATION // PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER .LINES PIT PRIVY <br /> _SEWAGE DISPOSJ- <br /> ELD CESSPOOL/SEEPAGE PIT.. OTHER <br /> INTENDED USE . TYPE' OF WELL CONSTRUCTIONjSPECIFICATIO S <br /> Industrial Cable Tool; Dia, of Well Excavation <br /> Domestic/private \, y Drilled Dia. of Well Casing <br /> Domestic/public Driven �4 Gauge of Casing ,-•4 LL� <br /> Irrigation Gravel Pack Depth of:Grout Seal. <br /> Other As Rotary. Type of Grout <br /> Other i Other Information <br /> PUMP INSTALLATION: Contractor <br /> fi Type .ofPump H.P. <br /> PUMP REPLACEMENT: /�/ State,Work Doe s <br /> PUMP REPAIR: / / State Work Done <br /> ttt <br /> DESTRUCTION OF WELL: Well Diameter Y 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)FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECUON PHAS II FINAL INSPECTION <br /> INSPECTION BY -feA 462 fa&,2{ DATE �/.y y INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />