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d1X11 SAN JOAQUIN 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=. ,, _ yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t1 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 /> `t� 8 t40� D3 <br /> JOB ADDRESS/LOCATION !/O � LIy�' NSUS TRACT S <br /> Owner's NameI T Phone <br /> f - �� Address City <br /> {�- <br /> Contractor's Name License Phone 36 y-'/6yd <br /> f <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /7 DESTRUCTION <br /> PUMP INSTAL I , /� REPAIR / / PUMP REPLACEMENT /_7 <br /> Othert/� <br /> �l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `: PIT PRIVY = <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> Domestic/private l Drilled <br /> Dia, of Well Casing <br /> Irrigation <br /> --.Domestic/public f Driven Gauge of Casing <br /> Irrigation { Gravel Pack Depth of Grout Seal o <br /> Other 1. Rotary Type of Grout <br /> C 4 <br /> 4 Other Other Information <br /> PUMP INSTALLATION: Contractor rQ <br /> E Type of Pump H.P. o <br />[ PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done eltle AL <br /> .DESTRUCTION 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,0'f'Calif ornia�pe,r.tafnirig. to.. _or, regulating well *construction:;-,With.in FIFTEEN DAYS <br /> after completion of' my-work on a neva well, I will furnish the San JoaquinLocal 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 PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDAfiE7J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . 73 <br /> F <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION._ <br /> E H 1426 7/72 1M <br />