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�/ °"* JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICF, USE: 160 �. Hazelton Ave. , Stockton, Cal. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-2- / /!c/ <br /> 7,2 -t3s <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 C C 701d . CENSUS TRACT S q� <br /> 1 - <br /> Owner's Name },� `-y� Zit Phone <br /> Address !1 D g t{_i S� �= i� �OfJF •nJ City <br /> Contractor's Name rLM^ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN /% RECONDITION / / DESTRUCTIONT /_7 <br /> PUMP INSTALLATION PUMP REPAIR /PUMP REPLACEMENT /_T <br /> Other 2/ 'I� tw„�,p re,p�iY <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal M <br /> Other Rotary Type of Grout 1 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor T <br /> Type of Pump T.H L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 /> and6the 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 0umlA <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / p <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ;; <br /> E H 1426 4/72 1M. <br />