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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; {209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete It 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 73 O 0 D VL1'fjRd3 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City �t,�-e <br /> Contractor's Name C'er- License ��/0 73'7Phone ZA 3.3-413 <br /> TYPE OF WORK_(Check):- NEW WELL / DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION '/ / PUMP'REPAIR '/ / "PUMP REPLACEMENT �_-- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY IV ' IV <br /> SEWAGE DISPOSAL FIELD g? - SPOOL/SEEPAGE PTT THER <br /> J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS k'`y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> O <br /> Domestic/private Drilled Dia. of Well Casing Z,4;5,:7s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,rQ <br /> Other 1,r Rotary Type of Grout - <br /> Other Other Information Qo <br /> (L <br /> 'UMP INSTALLATION: Contractor r S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ;DESTRUCTION.OF-WELL.: .Well-Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> i <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 and belief. <br /> SIGNED TITLE /�J/�j� <br /> (DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR_PWART4MIUSE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I AL INSPECT N <br /> INSPECTION BY DATE � _,1NSPECTION BY [. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M. <br />