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SAN JOAQUIN LOCAL HEALTH DISTRICT •s�- <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 1 YEAR FROM DATE ISSUED Date Issued <br /> €39t-� C4-111 06-14- (Complete In Triplicate) ZO / C)-i-& —,0# <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 oft e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a�Fr�a� o cENsus TRACT <br /> Owners NamebFv ,r/ [t 1rrb,�'�] � Phone <br /> Address �� D ` Oe Cit <br /> Contractor's Name �,..s License !/ !L--Phone - -W7d- <br /> toll <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / // PUMP REPLACEMENT f? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> h1 <br /> INI'ENDED 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 of Oe- <br /> Type of Pump c ed H.P. <br /> PUMP REPLACEMENT; j—/ State Work Done <br /> _ U <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 belief. <br /> SIGNED , ITLE <br /> RA LOT AN ON R RSE SIDE M <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,. DATEZ-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />