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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ';7j_ /SOGf/ <br /> I <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons�ct <br /> PP . <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> II <br /> JOB ADDRESSAOCATION T`]7/4 7^1/ Z --<-F_`_ - _ CENSUS TRACT <br /> Owner's Name Al. fif A A Phone <br /> Address XGI6 (' <br /> 1 City <br /> Contractor's Name .� 7 License #��6a Phone <br /> DEEPEN /_� RECONDITION / / DESTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL / _ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ E <br /> Other / / <br /> 7 V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia. of Well Casing j�✓ V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ;1 Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> i Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor///_-g7 <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done }. <br /> ,)ESTRUCTION OF WELL: Well Diameter Approximate Depth I <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 t e est of my knowledge and belief. <br /> SIGNED TITLE <br /> i,(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I <br /> APPLICATION ACCEPTED BY DATE .2 <br /> ADDITIONAL COMMENTS: <br /> F PHASE II GROUT INSPECTION PHAS II I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY v DATE z -� <br /> CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> 9 H 1426 7/72 1M <br />