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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. j[ r <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED ` Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fcir a permit to construct <br /> and/or install the work herein described. This application is made 'iri compliance with San Joaquin <br /> %County Ordinance No: ?1862 an the Rules and Regulations of the `San .laagiii Local Health District. <br /> JOB ADDRESS/LOCATION L r <br /> NSU T CT 0 -Crry-us <br /> f <br /> Owner's Name - , - Phoiie7 <br /> Q <br /> Address G }kc City.;.�y� <br /> Contractor's Name License 4f/ 9 Phone 3 - • .3 <br /> -TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT <br /> ` Other / / -- <br /> DISTANCE TO NEAREST: SEPTICtTANK.- SEWER LINES PIT PRIVY <br /> SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private F Drilled Dia. of Well Casing i <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation °Gravel Pack Depth of Grout Seal <br /> Other Rotaryo, Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor C'J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done } - <br /> PUMP REPAIR: 1 <br /> State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> - - i <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 true to the beat of my knowledge and belief. <br /> SIGNED TITLE <br /> (BRAW PLOT PLAN 0_N REVERSE SIDE) <br /> FUR -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I IAF _ INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE :Z"/ <br /> CALL FOR A GROUT INSFECTION., PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E B -1426 7/72 1M <br />