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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 A�-,3(0 (c� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date ,Issued a � <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 Regul ions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name . ' Phone a <br /> J <br /> Address D� _ _ U t_�.. � Cit- / / <br /> Contractor's Name 71L-! :`w pp.;, e e c. Lic4�� ,�,p a9 Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_7 RECONDITION /_% DESTRUCTION <br /> PUMP INSTALLATION .W PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 /> x Domestic/private Drilled Ilia, of Well Casing % J <br /> Domestic/public . Driven Gauge of Casing Ec. 4 <--.J— <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Other t'l - Rotary Type of Grout _ f:T�770 Art t _ <br /> Other Other Information <br /> � I <br /> PUMP INSTALLATION: Contractor 7 <br /> Type of Pump �'v H.P. <br /> j-- ', 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR:­ State Work Done <br /> - 1 <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 on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and`n6tiify them before putting the well in use. The above <br /> information is true to the best of,e-D knowledge an l[�1 " ef. <br /> SIGNED a �, `� TITLE <br /> isij rv' � <br /> r PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E I OUT INSPECN -PHASE <br /> UIWNAL INSPECT40N <br /> INSPECTION BY DATE =- INSPECTION BY DATE <br /> GALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 9 H 1426 _ .._ . 7/72 IN ; <br />