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SAN JOAQUII 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.�3� cf�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —1 _3 <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 Joaquinj <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /✓ '"IWC CENSUS TRACT ! <br /> Owner's Name Phone y 63 - 76 9 S` <br /> I <br /> Address Cit 4 <br /> Y <br /> Contractor's Name License #I [C ^o Phone <br /> TYPE OF WORKCheck): NEW WELL <br /> ( DEEPEN /__7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / -- <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �( <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation r__ _ �g <br /> Domestic/private. Drilled Dia, of Well Casing /per° i <br /> Domestic/public Driven Gauge of Casing /Q <br /> rri ation <br /> (!& <br /> 8 Gravel Pack Depth of Grout Sea]. r� <br /> Other _ Rotary Type of Grout v <br /> Other Other Information <br /> PUMP INSTALLATION: Contractorza Ole <br /> Type of Pump -H.P. <br /> PUPPP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRS State Work Done <br /> r <br /> ESTRUCTION OF WELL: Well Diameter i 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 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 'J / <br /> TITLE <br /> (D W LOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 'e) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I INAL INSPECTION <br /> INSPECTION BYd 1. MORYO <br /> INSPECTION BYE DATE c � <br /> CALL FOR A GROUT NSPECT G OUTING AND FINAL INSPECTION. <br /> E H 1426 jI/fi P� 7/72 1M <br />