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SAN JO Q LOCAL 14EALT.H 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 /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issue(* 02 <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 /> � [ 73!5z + .411 <br /> JOB ADDRESS/LOCATION _fir � �:. N CENSUS TRACT S S� <br /> Owner's Name r /-//J ►Q /Vj n! Phone <br /> Address 'f y- - d,4. oAj s7` _.....------ - City <br /> Contractor's Name eO License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN/ / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 - <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 /> Domestic/public Driven Gauge of Casing -L} <br /> Irrigation Gravel Pack Depth of Grout Seal 'jZ? <br /> Other Rotary Type of Grout <br /> Other Other Information ' r <br /> PUMP INSTALLATION: Contractor r <br /> - ---- - - - -- --- --- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <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 comp et ±tr <br /> or on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL S the well and notify them before putting the well .in use. The above <br /> information ihe est of my knowledge and belief. <br /> o <br /> SIGNED TITLEQ -rQAe <br /> (D4W PLOT PLAN ON REVERSE SIDEOA-, <br /> FOR DEPARTMENT, USE ONLY <br /> PHASE I 4 <br /> APPLICATION ACCEPTED BY ,fir DATE '" <br /> ADDITIONAL COMMENTS: '✓ <br /> PHASE II GROUT INSPECTION 7 PHASE-II/F NALSPECTION <br /> INSPECTION BY DATE - INSPECTION BYAD <br /> r` `. -- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />