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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fFOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 0 <br /> i� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION 7 /L- CENSUS TRACT $f/ <br /> Owner's Name <br /> cj-z-«'� c:-.1��-� Phone <br /> Address G City <br /> M <br /> f Contractor's Name License 4 Phone 36%yZA <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN / J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT —` <br /> Other <br /> If <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE a TYPE OF WELL CONSTRUCTION SPECIFICATIONS +�1 <br /> s industrial j' Cable Tool Dia. of Well Excavation <br /> Domestic/private ii Drilled Dia. of Well Casing '# <br /> Domestic/public E Driven Gauge of Casing <br /> Irrigation Gravel Pack \-_ Depth of Grout Seal <br /> Other it Rotary Type of Grout <br /> .Other ' Other Information <br /> x r i N <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> IM <br /> PUMP REPLACEMENT: / State Work Done ` <br /> 7— <br /> PUMP REPAIR. ,X. J / State Work Do <br /> ne\ •, �':�� <br /> mow^ cArks_ _ <br /> .PES_TRUCTION OF WELL: Well Diameters t. Approximate Depth <br /> t T 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 ofilthe 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 w TITLE 4 - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _.__.._._..FOR DEPARTMENT USE ONLY <br /> PHASE I �I. <br /> APPLICATION ACCEPTED BY11 DATE �-- /9-/7 J <br /> ` ADDITIONAL COMMENTS: . il <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,<2_ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 11 t 7/72 lM <br />