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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. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued , �.`-_7a <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/LOCATION 1V70j&. Wbodh1`J` 2 CENSUS TRACT s <br /> ��,Owner's Name �/f1�l� [ ► - -- - ._ Phone-%ff�/Z_z.-•- . <br /> Address ( C� �ji?✓` City <br /> Contractor's Name License # Phone / <br /> r <br /> TYPE OF WORK {Check)-; NEW WELL DEEPEN %f RECONDITION /_7 DESTRUCTION /_7 M <br /> PUMP INSTALLATION / / PUMP REPAIR / f PUMP REPLACEMENT /7 <br /> Other /_7 T <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 /> p ! <br /> Domestic/private Drilled Dia. of Well Casing J <br /> Domestic/public Driven Gauge of Casing 1 . c,_ <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. I <br /> 5, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> E _ <br /> ,PESTRUCTION- 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 /> t information is true to the best of my knowledge and belief. <br /> SIGNED ., TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> h PHASE I <br /> fi APPLICATION ACCEPTED BY / DATE //--� 0 <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 77 DATE �2- INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ,Q <br /> [ E H 1426 7/72 1M <br />