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SAN JOAQUIDI-LOCAL HEALTH DISTRICT <br /> 1 FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif.. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoZ6 L <br /> , /p <br /> THIS PERMIT EMPIRES .1. YEAR FROM DATE -ISSUED Date Issued � � <br /> '-(Complete In Triplicate) <br /> Application is hereby made .to the SanJoaquinLocal 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-_an' the Rules: and Regulations of the San Joaquin Local Health District. T <br /> JOB ADDRESS/LOCATION922 <br /> CENSUS TRACT11 4 <br /> Owner.'s=Name'[ - /� <br /> .: Phone `17'`Cl <br /> Address _ <br /> _ ? <br /> . .. - . ,. City <br /> ,Contractor's Name <br /> f. License � 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN♦ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _62 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> INTENDED 115E T � --- <br /> YPE OF WELL 'CONSTRUCTION SPECIFICATIONS Cu <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 PackE Depth of Grout Seal �. f _ + <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contracttor*-�* <br /> Type of Pum J <br /> YP P <br /> H.P. <br /> PUMP `REPLACEMENT: / / State Work Done i <br /> 4 <br /> PUMP REPAIR: / / State Work Done t <br /> v <br /> ,DESTRUCTIONOF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> 1r. <br /> 4. <br /> I hereby agree to comply withiall :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 i true to the best of y knowledge 'and belief. <br /> C� <br /> SIGNEDTITLE <br /> i 007 .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE Il GROUT 'INSPECTION PHASE III/FINAL INSRECTIO <br />; INSP,ECTION BY DATE INSPECTION BY 4& DATE oZ <br /> CALL FORA GROUT_ .INSPECTION PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 117.V � <br />