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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave, <br /> 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 <br /> 2_(e 2- f8­6' ! Date Issued _L <br /> Cry _ (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 6v r441 C- 1 <br /> /j ►' _ NSUS TRACT SI-16 <br /> Owner's Name <br /> Phone <br /> Address "` <br /> f City <br /> Contractor's Name <br /> ' �'`'......... License # Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> / DEEPEN /_7 RECONDITION /_/ DESTRUCTION /_7 3� R <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other j / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITi <br /> i <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATI <br /> j CONS N <br /> able Tool Dia. of Well Excavation ! E <br /> Domestic/private Drilled � <br /> ' Dia. of Well Casing:' <br /> _ Domestic/public Driven r G <br /> Irrigation GGauge of Casing , <br /> ravel .Pack '°Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> I Other Other Information j <br /> PUMP INSTALLATION: Contractor <br /> Type- of Pump <br /> H.P. / <br /> sS— <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP!Maw /_11 State Work Donee -� <br />,DESTRUCTION OF WELL: Well Diameter VJ4� <br /> Describe Material and Procedure Approximate Depth _ <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 thewell in use. The above <br /> information is true to the best k, wledge a d heli <br /> SIGNED= <br /> ITLE <br /> ( W PLOT PLAN ON - ERSE SIDE <br /> PHASE IOR DEPARTMENT USE ONLY <br /> k.PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ls'-77 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHASE III FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE 4 x_p-713 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M 00) f <br />