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J - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICEVUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> E <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 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 D CENSUS TRACT <br /> F Owner's Name o. T P R/ 616 S R Phone 3!3 02 <br /> Address 7 h-h�-R aKeE /2 p -- City S 7-&IV <br /> Contractor's Name License # X65 6f Phone 4r641g�i� <br /> TYPE OF WORK (Check): NEW WELL /—f 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 /> - c <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �( Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information O <br /> 6 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. oZ <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR, / / State Work Done <br /> { <br /> , ESTRUCTION 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 <br /> TITLE <br /> (DRAW T PLAN ON REVERSE SIDE <br /> 1 <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY� <br /> APPLICATION ACCEPTED BY �.� DATE 611117_,? j F <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHAS NINSPECTION <br /> INSPECTION BY DATE el INSPECTION BY DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 <br /> 7/72 1M ' <br /> A <br />