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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE USE: "1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <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 /> z <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 C.�1dlL �/ L4 112A.01 CENSUS TRACT <br /> I. <br /> Owner's Name <br /> Phone a )L <br /> Address <br /> City /�.e, C046- <br /> Contractor's Name/ 3 1¢ d r, ' ' ' License #// �` ' Z-- r76 <br /> �,� .� . Phone _ F,�,� <br /> F `TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION 'S// —' PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / 7. <br /> f DISTANCE TO NEARESTi <br /> SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing s <br /> k Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> —7— Rotary Type of Grout <br /> F Other Other Information <br /> 1 <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> REPAIR:-PUMP REPAZR � i <br /> / / 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 oi.a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 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 <br /> TITLE <br /> (DRAW- PLOT--PLAN ON REVERSE SIDE) i <br /> PHASE I <br /> FOR DE MENT USE ONLY <br /> � <br /> APPLICATION ACCEP DATE � �`77 <br /> ADDITIONAL COMMENTS: <br /> SE GROUT INSPECTION P Z NAL INSPECTION <br /> INSPECTION BY DATE — ON BY Cl DATE Z <br /> CALL FOR A ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. r <br /> E H 1426 4/72 1M <br />