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SAN JOAQUIN LOCAL HEALTH DISTRICT ( t711 <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 { <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE .ISSUED Date Issued3 <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/LOCATIO o 9 <br /> _ � , . � �-� CENSUS TRACT <br /> Owner's Name <br /> Address C - a� G-��S ' Cityx <br /> t ! r <br /> Contractor's N'�me License # //Z-f-2-2--Phone 18 <br /> �Syew <br /> TYPE 'OF-WORK-,(Check)-:-;4-,,NEW:;�WEL-Lx/-Pl!�'DEEP_EN-./.-/-RECONDITION' /7--;-DESTRUCT: ONT/�-' ,- <br /> PUMP INSTALLATION / / PUMP REPAIR ,,/ / PUMP REPLACEMENT /- <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: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> DESTRUCTION OF 'WELL: Well Diameter o7 Approximate Depth 77 <br /> Describe Material and Procedure <br /> i <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 'Z&2 rs° <br /> ��RAWPLO <br /> TITL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION .BY DATE INSPECTION BY DATE ?-7 <br /> CALL FOR A GROUT :INSPECTION .PRIOR, TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 :� , 7/72 1M <br />