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"4N JOAQUIN LOCAL HEALTH DISTRIC- <br /> FOR OFF USE: 19`/ E. Hazelton Ave. , Stockton, Cam. <br /> Telephoner (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7a- �/l uJ <br /> ` 7z_t3s,r <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 /> nd/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 /> //►� <br /> LJOB ADDRESS/LOCATION oG � CENSUS TRACT J V4 <br /> 1 <br /> Owner's Name n Phone <br /> Address 7 Q g / p�J� 7 City <br /> Contractor's Name �L _p License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR � nPUMP REPLACEMENT <br /> Other �� q �tcrPli� <br /> LDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> L INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private c' 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 <br /> f Other Other Information <br /> L � <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. t f <br /> PUMP REPLACEMENT: L/ 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 /> andothe 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 l7(�jn,t� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ii.PHASE L< <br /> APPLICATION ACCEPTED BY DATE�yL-r.�t�tl7` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 4WFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `//� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 14/72 1M. <br />