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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1/1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> k County Ordinance No. 1862 and the "Rules and Regulations of the- San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a to �� Jr 7i�-�c � ,.� CENSUS TRACT <br /> Owner's Name �rt�c�P/1 Phone <br /> Address G 1-,v"J4 -- City -a <br /> Contractor's Name 5F;;7 License # 'P,6o(P1 Phone <br /> �-v z <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /fes PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> PUMP INSTALLATION: Contractz� Ce, � �j <br /> Type of Porump H.P. <br /> I <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 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 truet he best of my knowledge and belief. <br /> SIGNED � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIYE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY g�2 <br /> - DATE A2--�Z -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I ,/ AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ! w DATE /�, W <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> t <br /> E H 1426 7/72 1M <br />