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SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 7r/ice <br /> THISI 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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J ~D / Gu a l>t �P['G" CENSUS TRACT <br /> Owner's Name Ile k Phone Z 3 L J <br /> Address i I� l46 City /� dt �r <br /> I / <br /> Contractor's Name cf / �° t v-/�. jl lu/2 � �� License #,2f Phone <br /> TYPE OF WORK (Check): NEW WELL /^fi DEEPEN /_/ RECONDITION /_� DESTRUCTION /� q <br /> PUMP INSTLATION />� PUMP REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other / / �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (n <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial d Cable Tool Dia. of -Well Excavation ' <br /> Domestic/private i Drilled Dia. of Well Casing _ 1 <br /> Domestic/public i Driven Gauge of Casing F <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> i Other Other Information _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> IVI <br /> PUMP REPLACEMENT: / / Sate Work Done <br /> PUMP REPAIR: / / State Work Done A <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withi 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 we . use. The abre <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> 1 (DRAW .PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE. r <br /> 1 ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTIONPHA I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a6 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING.AND FINAL INSPE ON. <br /> E H 1426 7/72 1M <br />