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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 0-R ' FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- 1,5-294c,) <br /> THIS PERMIT EXPIRES I 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 const ct <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 CENSUS TRACT <br /> �yy, <br /> Owner's Name �/IlM�' �1/1P�[1l� -- - ----- Phone <br /> Address WG 16 � - City ZMA&9 <br /> Contractor's Name �. �22 License ��� Phone <br /> � �6u <br /> { <br /> TYPE OF WORK (Check) : NEW WELL /Z:�P'D EEPEN /_7 RECONDITION /—T DESTRUCTION /-7 <br /> PUMPINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Otherl/ <br /> V <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial I Cable Tool Dia, of Well Excavation V <br /> Domestic/private 11 Drilled Dia. of Well Casing fp✓ �! <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation j Gravel. Pack Depth of Grout Seal _ <br /> Other II Rotary Type of Grout <br /> �f Other Other Information <br /> ' PUMP INSTALLATION: Contractors- //: <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 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 therwell and-notify them before putting the well in use. The above <br /> :<,information isytrue to t e est of my knowledge and belief. <br /> k <br /> SIGNED TITLE <br /> LORAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I ,IW INSPECTION <br /> INSPECTION BY DATE - - INSPECTION BY DATE, _ 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />