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J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 r' T Ea :, ;3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP°PERMIT `Pe it No. I-L45L u/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 3 <br /> (Complete In Triplicate) ( ot(_200_d <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <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/LOCATIONS ' CENSUS TRACT <br /> Owner's Name Phone <br /> 6r F <br /> Address City <br /> Contractor's Name , /'� ^� License y PhoneAL <br /> TYPE OF WORK (Check) : NEW WELL ILS DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> 6� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD • CESSPOOL/SEEPAGE PIT OTHER r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia, of Well Excavation f <br /> k Domestic/private t.- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0f . <br /> Irrigation Gravel Pack Depth of Grout Seal • — <br /> Other y Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 2 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 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 _ ( � 6--z _ TITLE ---- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> - --- - - FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ayd DATE — --- <br /> ADDITIONAL COMMENTS: <br /> PHASE 11tGRQUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE W% er INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />