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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. <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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ,nd the Rules Rules and Regu_latio of the San Joaquin Local Health District. <br /> JOB ADDRESS/4PBATM <br /> V' AkiJ1 A4 CENSUS TRACT <br /> Owner's Name t ..4AA'rl Rhone <br /> Address <br /> City <br /> Contractor's Name f �� Licensehone ,, <br /> TYPE OF WORK (Check) : NEW WELL /fy DEEPEN �/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION TV PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD " r/SEEPAGE PI OTHER /vf� ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tata <br /> Industrial <br /> Cable Tool Dia, of Well Excavation <br /> OK Domestic/private Drilled Dia. of Well- Casing <br />- Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <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 /> PUMP REPAIR: / / State Work Done <br />,pESTRUCTION 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY J� DATE71 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />