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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. Z <br /> jyq <br /> THIS PERIMIT-EXPIRES I YEAR FROM DATE ISSUE Dade 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`Ruies and`'Regulations of the San Joaquin Loc" a1 Health District. <br /> JOB ADDRESS/LOCATIONCENSUS T1tACT `f5'- 04o r7 , <br /> . . <br /> r <br /> Owner's Name <br /> Phone `.2 <br /> Address v <br /> - . .. ... . ... ....._City �_. - � <br /> Contractor's Name &�4-SQ6-0 <br /> License # �zd Phone �y�o <br /> TYPE OF WORK (Check).: NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /J <br /> - a • <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 r7 , <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal � r <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done — <br /> 1R <br /> PUMP REPAIR: . r / / State Work Done &I a <br /> 60f4CISa) PRD <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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 Distric'C"a 1 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr ejto the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL COMMENTS: 3 <br /> PHASE II GROUT INSPECTION P III Z INSPECTION <br /> INSPECTION BY DATE INSPE ON BY ATE - Z <br /> CALL FOR A GROUT INSPECTION .PRIOR,TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 N 1 7/72 . IM'i" ,� } <br />