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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160i,w . Hazelton Ave . , Stockton, Calms. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a 3 /�z CENSUS TRACT <br /> Owner's Name CC,v1� =-..;' v�0 2r Phone <br /> Address 3 / Cityec�7�Co�� <br /> Contractor's Name License # /93 7y-4 Phone ✓GJ - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Qther / / — <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ X/ 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 tl <br /> Othert Other Information 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S c. h H.P. <br /> PUMP REPLACEMENT: /u/ State Work Done <br /> PUMP REPAIR: L/ 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 /> informatio�n- is true to the best of my knowledge and belief. <br /> SIGNED ., %� l'- ��t�;�TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE 111112v <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> 9. <br /> E H 1426 7/72 1M <br />