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SAN JOAQUIN LOCAL HEALTH DISTRICTy( ✓� <br /> 1601 E <br /> (J . Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: � <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 /> (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 Sari Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION t <br /> C Owner's NameQ'ell Phone , <br /> Y 4 ' <br /> Address o� p rZbr � i� Cit <br /> Contractor s Name <br /> v T� a`� License �� . / �tS''Phone 74'71 <br /> �4TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION I_7 ` BESTRUCTIOI3 /-7 <br /> PUMP INSTALLATION IXl -PUMP REPAIR / / PUMP REPLACEMENT l <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 /> _ )C_ Domestic/public Driven Gauge of Casing __ M <br /> Irrigation _...Gravel Pack >-- -Depth of Grout Seal �^{ <br /> Other Rotary Type of Grout 4� <br /> Other Other Information <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P//. <br /> PUMP / State Work Done <br /> y° PUMP REPAIR: f J State Work Done <br /> t r <br /> k 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 iaell, 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 any nowledge and belief. <br /> TITLEr-cc- <br /> # SIGNER ` ]PAW L T LAN ON RE RSE SIDE - - <br /> OR DEPARTMENT USE ONLY <br /> PHASE I BATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 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 AWV <br />