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y�O 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. ,Z3-</J/eJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L:- -�-3 <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 /> Cotmty Ordinance No. 1862 And the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 51 5f4e parkile f s ( oil 26)7 . CENSUS TRACT r <br /> Owner's Name 42,0Phone <br /> Address IV, / ¢' City <br /> Contractor's Name f -�/ //'�11 License # 102 Phone <br /> TYPE OF WORK (Check) : NEW WELL ;4' DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /-7 <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 V- <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 0 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 7� <br /> PUMP INSTALLATION: Contractor 91 97P <br /> Type of Pump ULA_ ._ .._ 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 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 � a, TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (( b <br /> APPLICATION ACCEPTED BY W �• 't ATE <br /> ADDITIONAL COMMENTS: ". <br /> PHASE II GROUT INSPECTION I INSPECTION <br /> INSPECTION BY'-j-,13 DATE -Z .—,-I-7�? � TION ATE _3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M :� <br />