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k <br /> SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> XOA OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION"OR PUMP PERMIT Permit No.J3�.-4 , <br /> 7__?-3 8',5? <br /> THIS 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' hersin 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 /> JOB ADDRESS/LOCATION CENSUS TRACT S <br /> I 1 - <br /> owner's Name ray , Phone 7-3 5CO 0 <br /> i <br /> Address City <br /> Contractor's Name L:J License 1E/4 ] 373 Phone3 ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN J J RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION f5' PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE' TO`NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT OTHER �. <br /> 4D <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing' <br /> F X Irrigation Gravel Pack Depth of Grout Seal , <br /> Other Rotary Type of Grout <br /> t Other " Other' Information <br /> PUMP INSTALLATION-:- Contractor SCJ <br /> r. .. Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done f <br /> r <br /> PUMP REPAIR: / /_ _.State_Work"Done <br /> , JDESTRUCTION 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..Calif.ornia .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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ` — <br /> ADDITIONAL COMMENTS: "-� <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY /'a/ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.. <br /> t <br /> E H 1426 7/72 1M <br />